INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, Inc. 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) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on a consent form in one of seven client records reviewed.
Client #5 was admitted on August 16, 2023 and was discharged on October 26, 2023. A release of information form was signed and dated by the client on August 16, 2023. The consent form documented a website link as the name of the person, agency, or organization to whom the disclosure was made to, which is not a specific enough identification.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An agency wide training on Releases of Information video was recorded and distributed to all staff by our Clinical Training Coordinator. In this training, she reviews how to fill out releases properly. The training will be shown to all staff in this program during their staff meeting and related back to the audit findings. Additionally, a training document with screen shots of how to properly fill out the releases were made and will be distributed to all staff for reference.
Clinical Coordinator will utilize a tracking system to ensure all consents are completed properly and updated prior to date of expiration. Clinical Coordinator and Clinical Supervisor will monitor weekly to ensure consents are in compliance with confidentiality laws and regulations. In addition, Clinical Manager will audit a minimum of five charts monthly to ensure consents are completed as expected and include the specific information to be disclosed for each consent completed. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of a disclosure on a consent form in one of seven client records reviewed.
Client #2 was admitted on July 13, 2023 and was still active at the time of inspection. A release of information form to a government agency was signed and dated by the client on July 13, 2023 and the form did not include the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An agency wide training on Releases of Information video was recorded and distributed to all staff by our Clinical Training Coordinator. In this training, she reviews how to fill out releases properly. The training will be shown to all staff in this program during their staff meeting and related back to the audit findings. Additionally, a training document with screen shots of how to properly fill out the releases were made and will be distributed to all staff for reference.
Clinical Coordinator will utilize a tracking system to ensure all consents are completed properly and updated prior to date of expiration. Clinical Coordinator and Clinical Supervisor will monitor weekly to ensure consents are in compliance with confidentiality laws and regulations. In addition, Clinical Manager will audit a minimum of five charts monthly to ensure consents are completed as expected and include the specific information to be disclosed for each consent completed.
For client #2--Staff contacted the client to obtain a corrected consent wherein the purpose of the disclosure was indicated.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of five applicable client records reviewed.
Client #2 was admitted on July 13, 2023 and was still active at the time of inspection. The comprehensive treatment plan was completed on August 25, 2023 and the first update was due no later than October 25, 2023; however, the update was not completed until January 5, 2024.
Client #3 was admitted on September 21, 2023 and was still active at the time of inspection. The comprehensive treatment plan was completed on October 25, 2023 and the first update was due no later than December 25, 2023; however, the update was not completed until January 10, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Coordinator will establish a system to track and verify the punctuality of treatment plan updates. Weekly, the Clinical Coordinator will monitor the initial and master treatment plans that are due. A list of treatment plan deadlines for each client on their caseload will be emailed to all clinical staff every week. For any overdue treatment plans, the Clinical Coordinator will follow up with the staff to determine if the client is pending discharge and needs discharge paperwork completed. The Clinical Manager will conduct a monthly review for compliance. Additionally, the Clinical Coordinator will review timely discharge procedures in her staff meeting. The Clinical Manager will also oversee and ensure the timeliness of discharges, maintaining adherence to the agency's policies. |