INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Silver Linings USA Limited Liability Company 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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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that all counselor assistants documented to the facility director that they are working towards counselor status upon the completion of each calendar year in one of one applicable personnel records. Employee #5 was hired as a counselor assistant on December 21, 2021. There was no documentation to the facility director, in the record, indicating that the employee was working towards counselor status at of the end of the 2023 calendar year.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has created a template for current and any potential counselor assistants that will state the status of each employee working toward getting counselor status that will be given to the facility director. This form is now being implemented effective 8/30/24 as well as will be put in current counselor charts for any employees that did not have it in their chart from previous years to get their HR chart in compliance. For new employees that are counselor assistants this form will be due on their hire date each year. This will be monitored by the Clinical Director completing HR chart audits on a monthly basis. At this time if the counselor assistants do not have this form completed they will be notified or given the date when it will be due (i.e hire date).
The current counselor assistant will have this form completed for previous
The form has been implemented effective 8/30/24 for current counselor assistant. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor assistant completed 30 clock hours of training annually (after the first year) in one of one applicable personnel record reviewed. Employee #5 was hired as a counselor assistant on December 21, 2021. There were zero clock hours of training documented during the December 21, 2022 through December 21, 2023 in the personnel record at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has a new system in place that includes a tracking system of all the CEUS that each employee is required and when they are each due. HR will them make sure to notify the staff member of when they will need to get their hours completed by. If the employees do not get their trainings completed by the time frame needed they will be docked pay until they get them done. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's October 2023 through July 2024 fire drill log, the facility failed to ensure that their written fire drill log included documentation of problems encountered and whether the fire alarm or smoke detector was operative at the time of the drill. Every monthly fire drill log documented during the reviewed period did not include any documentation of problems encountered and if the fire alarm or smoke detector was operative during the time of the drills. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has created an updated fire drill log where there is a spot to check off that the fire drill and smoke detectors were operating during drill. There is also a space to document any problems or lack of problems that were encountered during drill. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility failed to document, and make available to the public, an annual report which is to include, but not be limited to, a statement disclosing the names of officers, directors and principal shareholders.This is a repeat citation from the September 15, 2022 and October 3, 2023 annual licensing renewal inspections.This finding was discussed with facility staff during the licensing process.
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Plan of Correction
The facility has since put up a form in the client area that shows the names of the officers, directors, and principle shareholders. The facility will also make sure to put this on their website in a place that is visible to anyone who visits the site. This will be updated if needed if anything shall change immediately on both the website and on site. |
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 is made to on a consent to release information form in one of fourteen client records reviewed. Client # 8 was admitted to the outpatient activity on February 13, 2024 and was still active at the time of the inspection. There was a blank release of information form signed by the client on February 13, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All consents to release information will be documented correctly making sure that all information is documented including the name of the person, agency, or organization to whom the disclosure is made to. The counselor or counselor assistant will be in charge of checking those releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the director as well.
All charts have been audited by Clinical Director and notified clinical team which consents to release information forms needed to be updated and put any information necessary to make the releases compliant.
The ROI for client #8 was corrected 8/30/24. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in two of fourteen client records reviewed. Client # 8 was admitted to the outpatient activity on February 13, 2024 and was still active at the time of the inspection. There was a release of information form to the pharmacy signed by the client on February 13, 2024; however, the form did not include the specific information to be disclosed. Client # 14 was admitted to the outpatient activity on March 15, 2024 and was discharged on July 9, 2024. There was a release of information form to the referral source signed by the client on March 24, 2024; however, the form did not include the specific information to be disclosed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All consents to release information will be documented correctly- ensuring that all information is documented including the name of the person, agency, or organization to whom the disclosure is made. The counselor or counselor assistant will hold the responsibility to check said releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the director for review.
All charts have been audited by Clinical Director who has notified clinical team which consents to release information forms required update in order to make the releases compliant. This will be a part of the clinical audit that goes out to clinical team once a week on Mondays.
The ROIs for client #8 and client #14 were corrected on 8/30/24. Information was updated to reference the receiver of information and the nature of the information to be disclosed.
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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 the disclosure on consent to release information forms in thirteen of fourteen client records reviewed. Client # 1 was admitted to the partial hospitalization activity on July 8, 2024 and was still active at the time of the inspection. There was a release of information form to the pharmacy signed by the client on July 9, 2024; however, the form did not include the purpose of the disclosure.Client # 2 was admitted to the partial hospitalization activity on July 22, 2024 and was still active at the time of the inspection. There was a release of information form to the pharmacy signed by the client on July 25, 2024; however, the form did not include the purpose of the disclosure.Client # 3 was admitted to the partial hospitalization activity on February 12, 2024 and was discharged on March 8, 2024. There was a release of information form to the pharmacy signed by the client on February 12, 2024; however, the form did not include the purpose of the disclosure.Client # 4 was admitted to the partial hospitalization activity on January 15, 2024 and was discharged on February 26, 2024. There was a release of information form to the pharmacy signed by the client on January 15, 2024 however, the form did not include the purpose of the disclosure.Client # 5 was admitted to the partial hospitalization activity on January 15, 2024 and was discharged on January 29, 2024. There was a release of information form to the pharmacy signed by the client on January 15, 2024; however, the form did not include the purpose of the disclosure.Client # 6 was admitted to the partial hospitalization activity on January 17, 2024 and was discharged on February 26, 2024. There was a release of information form to the pharmacy signed by the client on January 17, 2024; however, the form did not include the purpose of the disclosure.Client # 7 was admitted to the partial hospitalization activity on February 29, 2024 and was discharged on March 6, 2024. There was a release of information form to the pharmacy signed by the client on February 19, 2024; however, the form did not include the purpose of the disclosure.Client # 8 was admitted to the outpatient activity on February 13, 2024 and was still active at the time of the inspection. There was a release of information form to the pharmacy signed by the client on February 13, 2024; however, the form did not include the purpose of the disclosure.Client # 10 was admitted to the outpatient activity on February 5, 2024 and was still active at the time of the inspection. There was a release of information form to the pharmacy signed by the client on February 5, 2024; however, the form did not include the purpose of the disclosure.Client # 11 was admitted to the outpatient activity on February 26, 2024 and was discharged on May 28, 2024. There was a release of information form to the pharmacy signed by the client on January 15, 2024; however, the form did not include the purpose of the disclosure.Client # 12 was admitted to the outpatient activity on January 29, 2024 and was discharged on March 18, 2024. There was a release of information form to the pharmacy signed by the client on January 15, 2024; however, the form did not include the purpose of the disclosure.Client # 13 was admitted to the outpatient activity on February 26, 2024 and was discharged on March 22, 2024. There was a release of information form to the pharmacy signed by the client on January 17, 2024; however, the form did not include the purpose of the disclosure.Client # 14 was admitted to the outpatient activity on March 15, 2024 and was discharged on July 9, 2024. There were release of information forms to the pharmacy and the parole agent signed by the client on March 15, 2024; however, the forms did not include the purpose of the disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All consents to release information will be documented correctly making sure that all information is documented including the name of the person, agency, or organization to whom the disclosure is made to. It will also make sure the purpose of disclosure is documented. The counselor or counselor assistant will be in charge of checking those releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the director as well.
All charts have been audited by Clinical Director and notified clinical team which consents to release information forms needed to be updated and put any information necessary to make the releases compliant. This was completed 8/30/24.
This will now be apart of the clinical audit that goes out to clinical team once a week on Mondays.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire on a consent to release information form in one of fourteen client records reviewed. Client # 8 was admitted to the outpatient activity on February 13, 2024 and was still active at the time of the inspection. There was a release of information form to the pharmacy signed by the client on February 13, 2024; however, the release form did not include a date, event, or condition upon which the consent would expire.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All consents to release information will be documented correctly making sure that all information is documented including the name of the person, agency, or organization to whom the disclosure is made to. It will also make sure the purpose of disclosure is documented. The release will also have a spot to show a date, event, or condition upon which the consent would expire. The counselor or counselor assistant will be in charge of checking those releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the director as well. This was reviewed in staff meeting 8/30/24.
All charts have been audited by Clinical Director and notified clinical team which consents to release information forms needed to be updated and put any information necessary to make the releases compliant. This was completed 8/30/24.
This will now be apart of the clinical audit that goes out to clinical team once a week on Mondays. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in two of two applicable client records reviewed.Client # 7 was admitted to the partial hospitalization activity on February 29, 2024 and was administratively discharged on March 6, 2024. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project. Client # 11 was admitted to the outpatient activity on February 26, 2024 and was administratively discharged on May 28, 2024. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project. This is a repeat citation from the October 3, 2023 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to client #11 being discharged in May 2024 unfortunately this client was not provided the correct services and was not given a proper notification of their discharge. All clinical staff has been given a training by the Clinical Director at their clinical meeting on 8/19/24. Moving forward any client that is to be involuntarily terminated will be given notice in writing of the decision why they are discharging client and will be uploaded into the client's EMR chart as well.
Clinical Director provided a training on 9/2/24 during staff meeting to the clinical team. The clinical director will make sure that this is being done by chart audits that go out every week on Monday which includes discharge clients. Clinical staff will be notified if chart is out of compliance.
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation, as part of their intake and admission process in four of seven client records reviewed. Client # 2 was admitted to the partial hospitalization activity on July 22, 2024 and was still active at the time of the inspection. There was no documentation of a psychosocial evaluation of the client in the record at the time of the inspection. Client # 4 was admitted to the partial hospitalization activity on January 15, 2024 and was discharged on February 26, 2024. There was no documentation of a psychosocial evaluation of the client in the record at the time of the inspection. Client # 6 was admitted to the partial hospitalization activity on January 17, 2024 and was discharged on February 26, 2024. There was no documentation of a psychosocial evaluation of the client in the record at the time of the inspection. Client # 7 was admitted to the partial hospitalization activity on February 29, 2024 and was discharged on March 6, 2024. There was no documentation of a psychosocial evaluation of the client 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
Client #2, #4, #6, and #7 psychosocial has been completed. All clinical staff has been given a training by the Clinical Director at their clinical meeting on 8/19/24 on how the psychosocial is apart of the intake process and needs to be done within the first 48 hours. Moving forward the clients will all have their psychosocial completed within 48 hours.
Clinical Director was not receiving bio-psychosocial assessments to be reviewed with a signature and that has now been rectified as of 8/30/24. Clinical Director will now include this in the audit report that goes out once a week on Mondays. If there is information not inputted in the assessment the staff who completed it will be notified and will need to complete it by the following day. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of five applicable client records reviewed.Client # 1 was admitted to the partial hospitalization activity on July 8, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 11, 2024, but the plan did not include the type and frequency of treatment and rehabilitation services.Client # 3 was admitted to the partial hospitalization activity on February 12, 2024 and was discharged on March 8, 2024. The individual treatment and rehabilitation plan was completed on February 14, 2024, but the plan did not include the type and frequency of treatment and rehabilitation services.Client # 4 was admitted to the partial hospitalization activity on January 15, 2024 and was discharged on February 26, 2024. The individual treatment and rehabilitation plan was completed on February 1, 2024, but the plan did not include the type and frequency of treatment and rehabilitation services.Client # 5 was admitted to the partial hospitalization activity on January 15, 2024 and was discharged on January 29, 2024. The individual treatment and rehabilitation plan was completed on January 24, 2024, but the plan did not include the type and frequency of treatment and rehabilitation services.Client # 6 was admitted to the partial hospitalization activity on January 17, 2024 and was discharged on February 26, 2024. The individual treatment and rehabilitation plan was completed on January 18, 2024, but the plan did not include the type and frequency of treatment and rehabilitation services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1, #3, #4, #5, and #6 treatment plans have all been updated to include the type and frequency of treatment and rehabilitation services. All clinical staff has been given a training by the Clinical Director at their clinical meeting on 8/19/24 on how to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan. The Clinical Director will audit charts and send out a report and let clinical staff know if treatment plans need to be corrected. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation, as part of their intake and admission process in four of seven client records reviewed. Client # 8 was admitted to the outpatient activity on February 13, 2024 and was still active at the time of the inspection. There was no documentation of a psychosocial evaluation of the client in the record at the time of the inspection. Client # 10 was admitted to the outpatient activity on February 5, 2024 and was still active at the time of the inspection. There was no documentation of a psychosocial evaluation of the client in the record at the time of the inspection. Client # 11 was admitted to the outpatient activity on February 26, 2024 and was discharged on May 28, 2024. There was no documentation of a psychosocial evaluation of the client in the record at the time of the inspection. Client # 14 was admitted to the outpatient activity on March 15, 2024 and was discharged on July 9, 2024. There was no documentation of a psychosocial evaluation of the client 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
Client #8, #10, #11, and #14 psychosocial has been completed. All clinical staff has been given a training by the Clinical Director at their clinical meeting on 8/19/24 on how the psychosocial is apart of the intake process and needs to be done within the first 48 hours. Moving forward the clients will all have their psychosocial completed within 48 hours.
Clinical Director was not receiving bio-psychosocial assessments to be reviewed with a signature and that has now been rectified as of 8/30/24. Clinical Director will now include this in the audit report that goes out once a week on Mondays. If there is information not inputted in the assessment the staff who completed it will be notified and will need to complete it by the following day.
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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 document an individual treatment and rehabilitation plan, which is to be developed with the client, in three of seven client records reviewed. Client # 8 was admitted to the outpatient activity on February 13, 2024 and was still active at the time of the inspection. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection. Client # 12 was admitted to the outpatient activity on January 29, 2024 and was discharged on March 18, 2024. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection. Client # 14 was admitted to the outpatient activity on March 15, 2024 and was discharged on July 9, 2024. There was no individual treatment and rehabilitation 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
Client #8, #12, and #14 have individual treatment plans completed in their chart. All clinical staff has been given a training by the Clinical Director at their clinical meeting on 8/19/24 on treatment planning and how this is an essential part of the client's treatment that needs to be created with the client and counselor/counselor assistant. The treatment plan needs to be developed within 7 days of intake. The initial treatment plan shall be completed day of intake. The Clinical Director will audit charts and send out a report and let clinical staff know if treatment plans need to be completed. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of four applicable client records reviewed.Client # 9 was admitted to the outpatient activity on January 8, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 19, 2024, but the plan did not include the type and frequency of treatment and rehabilitation services.Client # 10 was admitted to the outpatient activity on February 5, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 5, 2024, but the plan did not include the type and frequency of treatment and rehabilitation services.Client # 11 was admitted to the outpatient activity on February 26, 2024 and was discharged on May 28, 2024. The individual treatment and rehabilitation plan was completed on May 20, 2024, but the plan did not include the type and frequency of treatment and rehabilitation services.Client # 13 was admitted to the outpatient activity on February 26, 2024 and was discharged on March 22, 2024. The individual treatment and rehabilitation plan was completed on February 26, 2024, but the plan did not include the type and frequency of treatment and rehabilitation services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #9, #10, #11, and #13 treatment plans have all been updated to include the type and frequency of treatment and rehabilitation services. All clinical staff has been given a training by the Clinical Director at their clinical meeting on 8/19/24 on how to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan. The Clinical Director will audit charts and send out a report and let clinical staff know if treatment plans need to be corrected. |
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 review and update treatment and rehabilitation plans at least every sixty days in two of two applicable client records reviewed. Client # 9 was admitted to the outpatient activity on January 8, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 19, 2024 and an update was due no later than March 19, 2024; however, the update was completed on April 29, 2024. Client # 10 was admitted on February 5, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 5, 2024 and an update was due no later than May 5, 2024; however, the update was completed on May 22, 2024. This is a repeat citation from the September 15, 2022 and October 3, 2023 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors were given training at clinical meeting 8/19/24 on treatment plans and treatment plan reviews. Clinical Director sends out a weekly audit report they will let counselors know when a treatment plan review or new treatment plan is due. Clinical Director will notify CEO if there are consistent late entries in client's chart. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in two of three applicable client records reviewed.Client # 13 was admitted to the outpatient activity on February 26, 2024 and was discharged on March 22, 2024. There was no documentation of follow-up information in the record at the time of the inspection.Client # 14 was admitted to the outpatient activity on March 15, 2024 and was discharged on July 9, 2024. There was no documentation of follow-up information 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
The Clinical Director went over in the clinical meeting on 8/19/24 how we need to make sure that there is follow-up information in the client's chart before they discharge. Follow-up information will now be apart of the aftercare planning. The Clinical Director will complete audit reports and let clinical staff know if they do not have this in chart and when it needs to be completed by. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on an administrative review, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for failing to review and update treatment and rehabilitation plans at least every sixty days were submitted and approved by the Department for the September 21, 2021, September 15, 2022, and October 3, 2023 annual licensing inspections. Failing to review and update treatment and rehabilitation plans at least every sixty days was again found to be deficiency during the July 26, 2024 annual licensing inspection.Plans of correction for failing to document and make available to the public an annual report which is to include a statement disclosing the names of officers, directors and principal shareholders were submitted and approved by the Department for the September 15, 2022 and October 3, 2023 annual licensing inspections. Failing to document and make available to the public an annual report which is to include a statement disclosing the names of officers, directors and principal shareholders was again found to be a deficiency during the July 26, 2024 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The plan of corrections were not followed up on from previous audits. This has been addressed with the CEO, Clinical Director and Facility Director. This was also addressed in clinical meeting on 8/19/24. There will be consequences moving forward if clinical staff is not able to comply with having their charts stay in compliance.
Clinical Director will be going over trainings during staff meetings once a month on issues that occurred during this and previous corrective action plans to ensure this does not reoccur. Clinical Director will also be auditing charts on a weekly basis and clinical staff will be getting that once a week on Mondays.
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