INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 13, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Visualize Change, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document a dated signature of the client on release of information forms in one of seven client records reviewed.
Client #7 was admitted on October 21, 2024 and was discharged on December 19, 2024. There were release of information forms to a funding source and a government agency signed and dated by a witness on October 21, 2024; however, the dated signature of the client was not included on wither release of information form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will address the issue at quarterly staff meeting to ensure that all staff are vigilant in uploading the correct documents to the client files. These files were found after the inspection and were just not uploaded to the file. Random file audits will be done monthly to specifically identify that all signed paperwork is in the file. Also the completed files name will be changed once it is downloaded as to not have it confused with the original sent file which does not contain the client signature. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client in two of five applicable client records reviewed.
Client #3 was admitted on August 9, 2024 and was active at the time of the inspection. There was no individual treatment plan documented in the record at the time of the inspection.
Client #7 was admitted on October 21, 2024 and was discharged on December 19, 2024. There was no individual treatment plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan requirements will be addressed at the quarterly staff meeting. The requirements will be reviewed and each member shall sign off that they understand the requirements. All files will be reviewed monthly to assure that the treatment plans are up to date and appropriate. The Project Manager will be responsible for assuring all requirements are met and all treatment plans meet requirements |