INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 27, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Public Health Management Corporation d/b/a Chances 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in four of seven client records reviewed.
The facility's policy and procedure manual stated that the comprehensive treatment plan is to be completed within 30 days of the admission date. Additionally, the manual stated that case consultation notes would be completed every 90 days within the first year of treatment.
Client #1 was admitted on April 4, 2022 and was still active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than May 4, 2022; however, the treatment plan was not completed until September 20, 2022. Additionally, there were no case consultation notes documented in the record at the time of the inspection.
Client #2 was admitted on August 3, 2022 and was still active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than September 3, 2022; however, the treatment plan was not completed until October 4, 2022.
Client #3 was admitted on June 21, 2022 and was still active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than July 21, 2022; however, the treatment plan was not completed until October 12, 2022. Additionally, there were no case consultation notes documented in the record at the time of the inspection.
Client #5 was admitted on May 10, 2022 and was discharged on October 24, 2022. There were no case consultation notes documented in the record at the time of the inspection.
Client #7 was admitted on April 20, 2022 and was discharged on October 24, 2022. The comprehensive treatment plan was due to be completed no later than May 20, 2022; however, the treatment plan was not completed until September 23, 2022.
This is a repeat citation from the January 13, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and/or Program Director will conduct a training on implementing DDAP approved Plans of Correction, including for licensing code 709.24a3, with all staff responsible for implementing DDAP Plan of Correction and responsible for Treatment Plan Policy and Case Consultation Policy implementation. The training will occur by December 12th, 2022.
DDAP Plan of Correction implementation and Recovery Treatment Plan Policy and Case Consultation Policy will be discussed as standing agenda items at every weekly CHANCES Clinical staff meeting for review and follow-up. The Clinical Director and/or Program Director will attend to ensure reviews and follow-ups are discussed and planned during these meetings, and implemented.
Monitoring of Treatment Plan Policy and Case Consultation Policy implementation and documentation will occur with regular (e.g. quarterly) Quality Management file reviews. Results will be shared with the Program Director for follow-up.
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709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client #1 was admitted on April 4, 2022 and was still active at the time of the inspection. There was a documentation of contact made with an outside pharmacy on April 11, 2022; however, there was no client-signed release of information form documented in the record prior to the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and/or Program Director will conduct a training on 709.28c Confidentiality requirements for all staff. The training will occur by December 12th, 2022.
Monitoring of Confidentiality Release of Information disclosures and documentation will occur with regular (e.g. quarterly) Quality Management file reviews. Results will be shared with the Program Director for follow-up.
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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 disclosure is made on consent to release information forms in one of seven client records reviewed.
Client #3 was admitted on June 21, 2022 and was still active at the time of the inspection. There were 2 release of information forms in the record that did not include the name of a person, agency, or organization to whom the disclosure would be made to.
This is a repeat citation from the January 13, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and/or Program Director will conduct a training on implementing DDAP approved plans of correction , including for licensing code 709.28c1 Confidentiality requirements, for all staff. The training will occur by December 12th, 2022.
DDAP Plan of Correction implementation will be discussed as standing agenda items at every weekly CHANCES staff meeting for review and follow-up. The Clinical Director and/or Program Director will attend to ensure reviews and follow-ups are discussed and planned during these meetings, and implemented.
Monitoring of Confidentiality Release of Information disclosures and documentation will occur with regular (e.g. quarterly) Quality Management file reviews. Results will be shared with the Program Director for follow-up.
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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 dated signature of the date, event, or condition upon which the consent will expire on consent to release information forms in six of seven client records reviewed.
Client #1 was admitted on April 4, 2022 and was still active at the time of the inspection. There were release of information forms to the funding source, multiple government agencies, probation/treatment court, and other PHMC agencies, all dated April 4, 2022; however, none of the forms included a date, event, or condition upon when the consents would expire.
Client #2 was admitted on August 3, 2022 and was still active at the time of the inspection. There was a release of information form to an external agency, dated August 3, 2022; however, the consent form did not include a date, event, or condition upon when the consent would expire.
Client #3 was admitted on June 21, 2022 and was still active at the time of the inspection. There were release of information forms to an external agency and the funding source, both dated June 7,2022; however, both consent forms did not include a date, event, or condition upon when the consents would expire.
Client #4 was admitted on April 5, 2022 and was discharged on July 29, 2022. There was a release of information form to an external agency, dated February 7, 2022; however, the consent form did not include a date, event, or condition upon when the consent would expire.
Client #6 was admitted on March 17, 2022 and was discharged on August 17, 2022. There was a release of information form to an external agency, dated March 17, 2022; however, the consent form did not include a date, event, or condition upon when the consent would expire.
Client #7 was admitted on April 20, 2022 and was discharged on October 24, 2022. There was a release of information form to an external agency, dated April 20, 2022; however, the consent form did not include a date, event, or condition upon when the consent would expire.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and/or Program Director will conduct a training on 709.28c6 Confidentiality requirements for all staff. The training will occur by December 12th, 2022.
The CHANCES Authorization for Release of Information template will be revised to prompt for authorization start and end dates with date values suggested.
Monitoring of Confidentiality Release of Information disclosures and documentation will occur with regular (e.g. quarterly) Quality Management file reviews. Results will be shared with the Program Director for follow-up.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and that reasons for removing sections shall be documented in the record in four of seven client records reviewed.
Client #1 was admitted on April 4, 2022 and was still active at the time of the inspection. The client rights acknowledgement form did not include notification of this regulatory client right.
Client #2 was admitted on August 3, 2022 and was still active at the time of the inspection. The client rights acknowledgement form did not include notification of this regulatory client right.
Client #4 was admitted on April 5, 2022 and was discharged on July 29, 2022. The client rights acknowledgement form did not include notification of this regulatory client right.
Client #6 was admitted on March 17, 2022 and was discharged on August 17, 2022. The client rights acknowledgement form did not include notification of this regulatory client right.
This is a repeat citation from the January 13, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and/or Program Director will conduct a training on implementing approved DDAP Plans of Correction, including for licensing code 709.30(3) Client Rights requirements, for all staff. The training will occur by December 12th, 2022. Part of the training will be to ensure that the updated notice of Client Rights is used at Intake. All outdated Client Rights form templates will be removed from use at the CHANCES program by the December 12th date .
DDAP Plan of Correction implementation will be discussed as standing agenda items at every weekly CHANCES staff meeting for review and follow-up. The Clinical Director and/or Program Director will attend to ensure reviews and follow-ups are discussed and planned during these meetings, and implemented.
Monitoring of Client Rights notifications and documentation will occur with regular (e.g. quarterly) Quality Management file reviews. Results will be shared with the Program Director for follow-up.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in four of seven client records reviewed.
Client #1 was admitted on April 4, 2022 and was still active at the time of the inspection. The client rights acknowledgement form did not include notification of this regulatory client right.
Client #2 was admitted on August 3, 2022 and was still active at the time of the inspection. The client rights acknowledgement form did not include notification of this regulatory client right.
Client #4 was admitted on April 5, 2022 and was discharged on July 29, 2022. The client rights acknowledgement form did not include notification of this regulatory client right.
Client #6 was admitted on March 17, 2022 and was discharged on August 17, 2022. The client rights acknowledgement form did not include notification of this regulatory client right.
This is a repeat citation from the January 13, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and/or Program Director will conduct a training on implementing approved DDAP Plans of Correction, including for licensing code 709.30(4) Client Rights requirements, for all staff. The training will occur by December 12th, 2022. Part of the training will be to ensure that the updated notice of Client Rights is used at Intake. All outdated Client Rights form templates will be removed from use at the CHANCES program by the December 12th date .
DDAP Plan of Correction implementation will be discussed as standing agenda items at every weekly CHANCES staff meeting for review and follow-up. The Clinical Director and/or Program Director will attend to ensure reviews and follow-ups are discussed and planned during these meetings, and implemented.
Monitoring of Client Rights notifications and disclosures and documentation will occur with regular (e.g. quarterly) Quality Management file reviews. Results will be shared with the Program Director for follow-up.
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records in four of seven client records reviewed.
Client #1 was admitted on April 4, 2022 and was still active at the time of the inspection. The client rights acknowledgement form did not include notification of this regulatory client right.
Client #2 was admitted on August 3, 2022 and was still active at the time of the inspection. The client rights acknowledgement form did not include notification of this regulatory client right.
Client #4 was admitted on April 5, 2022 and was discharged on July 29, 2022. The client rights acknowledgement form did not include notification of this regulatory client right.
Client #6 was admitted on March 17, 2022 and was discharged on August 17, 2022. The client rights acknowledgement form did not include notification of this regulatory client right.
This is a repeat citation from the January 13, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and/or Program Director will conduct a training on implementing approved DDAP Plans of Correction, including for licensing code 709.30(5) Client Rights requirements, for all staff. The training will occur by December 12th, 2022. Part of the training will be to ensure that the updated notice of Client Rights is used at Intake. All outdated Client Rights form templates will be removed from use at the CHANCES program by the December 12th date .
DDAP Plan of Correction implementation will be discussed as standing agenda items at every weekly CHANCES staff meeting for review and follow-up. The Clinical Director and/or Program Director will attend to ensure reviews and follow-ups are discussed and planned during these meetings, and implemented.
Monitoring of Client Rights notifications and and documentation will occur with regular (e.g. quarterly) Quality Management file reviews. Results will be shared with the Program Director for follow-up.
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in seven of seven client records reviewed.
Client #1 was admitted on April 4, 2022 and was still active at the time of the inspection. The client rights acknowledgement form did not include notification of this regulatory client right.
Client #2 was admitted on August 3, 2022 and was still active at the time of the inspection. The client rights acknowledgement form did not include notification of this regulatory client right.
Client #4 was admitted on April 5, 2022 and was discharged on July 29, 2022. The client rights acknowledgement form did not include notification of this regulatory client right.
Client #6 was admitted on March 17, 2022 and was discharged on August 17, 2022. The client rights acknowledgement form did not include notification of this regulatory client right.
This is a repeat citation from the January 13, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and/or Program Director will conduct a training on implementing approved DDAP Plans of Correction, including for licensing code 709.30(6) Client Rights requirements, for all staff. The training will occur by December 12th, 2022. Part of the training will be to ensure that the updated notice of Client Rights is used at Intake. All outdated Client Rights form templates will be removed from use at the CHANCES program by the December 12th date .
DDAP Plan of Correction implementation will be discussed as standing agenda items at every weekly CHANCES staff meeting for review and follow-up. The Clinical Director and/or Program Director will attend to ensure reviews and follow-ups are discussed and planned during these meetings, and implemented.
Monitoring of Client Rights notifications and and documentation will occur with regular (e.g. quarterly) Quality Management file reviews. Results will be shared with the Program Director for follow-up.
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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, as part of their intake process, a psychosocial evaluation of the client in seven of seven client records reviewed.
In every client record reviewed, there was no documentation of a psychosocial evaluation as of the date of the inspection.
This is a repeat citation from the January 13, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and/or Program Director will conduct a training on implementing approved DDAP Plans of Correction, including for licensing code 709.91b6 Psychosocial Evaluations requirements, for all staff responsible for completing The Psychosocial Evaluations. Training will occur by December 12th, 2022. Part of the training will be to ensure that the updated Biopsychosocial Evaluation form with the Clinical Impressions section is used at Intake by the clinicians. All outdated Biopsychosocial Evaluation form templates will be removed from use at the CHANCES program by the December 12th date .
DDAP Plan of Correction implementation will be discussed as standing agenda items at every weekly CHANCES staff meeting for review and follow-up. The Clinical Director and/or Program Director will attend to ensure reviews and follow-ups are discussed and planned during these meetings, and implemented.
Monitoring of Psychosocial Evaluations documentation will occur with regular (e.g. quarterly) Quality Management file reviews. Results will be shared with the Program Director for follow-up.
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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 # 4 was admitted on April 5, 2022 and was discharged on July 29, 2022. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client # 5 was admitted on May 10, 2022 and was discharged on October 24, 2022. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client # 6 was admitted on March 17, 2022 and was discharged on August 17, 2022. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
This is a repeat citation from the January 13, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and/or Program Director will conduct a training on implementing approved DDAP Plans of Correction, including for licensing code 709.24a3, with staff responsible for implementing DDAP Plan of Correction and responsible for Treatment Plan Policy and Case Consultation Policy implementation. The training will occur by December 12th, 2022.
DDAP Plan of Correction implementation and Recovery Treatment Plan Policy and Case Consultation Policy will be discussed as standing agenda items at every weekly CHANCES Clinical staff meeting for review and follow-up. The Clinical Director and/or Program Director will attend to ensure reviews and follow-ups are discussed and planned during these meetings, and implemented.
Monitoring of Treatment Plan completion and documentation will occur with regular (e.g. weekly) Clinical Director reports on Treatment Plan completions and coming-due dates. Results will be shared with the Program Director and clinical staff for follow-up.
Monitoring of Treatment Plan completion and documentation will occur with regular (e.g. quarterly) Quality Management file reviews. Results will be shared with the Program Director for follow-up.
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