INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 23, 2024 through October 24, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, AWJWI, LLC d/b/a Sobriety Solutions Pennsylvania 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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of the policy and procedure manual, the project failed to develop written procedures for the management of treatment/rehabilitation services for clients that included timeframes on the completion of client case consultations.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
CCO revised the facility's Policies and Procedures to address lack of timeframes for the completion of client case consultations.
Leadership discussed the revision which stated that "case consolations will be completed for each client prior to discharge."
Case consultations were added to EMR system and all clinical staff has been updated and trained on case consultations, the timeframe for completion of client case consultations outlined in the Policies and Procedures and how to initiate the form in EMR system as of 11/8/2024. |
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.
|
Observations
Based on the review of client records, the project failed to obtain an informed a voluntary consent from the client for the disclosure of information contained in the client record in one of fourteen records reviewed.
Client #5 was admitted on August 19, 2024, and was discharged on September 20, 2024. On September 20, 2024, a facility staff member documented that there was communication between that facility staff member and another treatment provider; however, the facility did not obtain a release of information form, signed by the client, prior to making the disclosure.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
It was found that client #5 had their informed voluntary consent form deleted due to a misspelled name which was noticed after it was signed upon admission on August 19, 2024. A new voluntary informed consent was completed on September 6, 2024 in place of the deleted voluntary informed consent with the name spelled correctly.
Client #5 initial deleted voluntary informed consent was recovered and the release completed on August 19, 2024 is in current EMR chart and is "revoked" as the voluntary informed consent completed September 6, 2024 remains active.
Clinical Supervisor and CCO met with clinical staff to review HIPAA and confidentiality. Clinical Supervisor will audit all new clients chart upon admission to ensure all voluntary informed consents are completed. Clinical staff was also trained to revoke releases and to not delete any files from EMR pursuant to regulation 709.28 (c). |
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.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made to in one of fourteen records reviewed.
Client #12 was admitted on May 23, 2024, and was discharged on August 7, 2024. A release of information form, signed by the client on May 23, 2024, did not specify the name of the person, agency or organization to whom disclosure is to be made.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
It was found that in the client records for discharged client #12, informed and voluntary consents were blank and signed by the client. Pursuant to regulation 709.28(c)(1), Admission Director and CCO reviewed informed and voluntary consents. Admissions Director will conduct a weekly audit of all new client intakes informed and voluntary consents and remove any consents that are left blank from the client record. CCO and Admissions Director will review any informed and voluntary consents that are blank to ensure that the consent is in fact invalid and will be removed from client record. |
709.83(a)(11) LICENSURE Client records
709.83. 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.
|
Observations
Based on the review of partial hospitalization client records, the project failed to document a complete client record on an individual that included follow-up contact in four of four applicable records reviewed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Pursuant to regulation 709.83(a)(11), it was found that follow up contact was not documented for 4 of 4 partial hospitalization clients charts reviewed.
Leadership team met to identify and correct lack of follow up contact. All follow up contacts will be completed by Alumni Coordinator and documented in CRM.
COO will review all portal hospitalization discharges weekly and audit CRM of partial hospitalization discharged clients to ensure follow up contacts are made.
This policy will be on the weekly business development agenda to ensure follow up contact is being made and that facility its in compliance with regulation 709.83(a)(11) |
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.
|
Observations
Based on the review of outpatient client records, the project failed to document a complete client record on an individual that included follow-up contact in four of four applicable records reviewed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Pursuant to regulation 709.93(a)(11), it was found that follow up contact was not documented for 4 of 4 outpatient clients charts reviewed.
Leadership team met to identify and correct lack of follow up contact. All follow up contacts will be completed by Alumni Coordinator and documented in CRM.
COO will review all outpatient discharges weekly and audit CRM of outpatient discharged clients to ensure follow up contacts are made.
This policy will be on the weekly business development agenda to ensure follow up contact is being made and that facility its in compliance with regulation 709.93(a)(11) |