INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 28, 2018 of Bio-Care Recovery Inc by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Bio-Care Recovery 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:
|
Plan of Correction
|
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
|
Observations
During the physical plant inspection on August 28, 2018, the facility failed to ensure that a fire exit door located in the physician's office was easily accessible. The door was sticking when trying to open and was difficult to close.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
705.28 (a) (1) (i) LICENSURE
Fire safety.:
705.28. Fire safety. (a) Exits. (1) The nonresidential facility shall: (i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
POC: The door in question was difficult to open, but more difficult to close, therefore exiting the building was not an issue when we did a fire drill August 28 at 4:00 pm. The Program Director opened and closed the door daily to ensure it worked and notified our landlord of the issue.
Anticipated Completion Date: On September 13, 2018, our landlord shaved the door jamb to provide easier opening and closing of the door. He also replaced the hardware strike plate to provide a more secure locking mechanism.
|
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 a review of client records, the facility failed to to obtain an informed voluntary consent in two of seven records viewed.
Client # 3 was admitted on May 17, 2018 and was still an active client at the time of the inspection. A correspondence with a pharmacy occurred on June 7, 2018 and there was no consent to release information completed by the client in the client record.
Client #5 was admitted on October 25, 2017 and was discharged on June 29, 2018. A consent to release form to an insurance company dated October 25, 2017 did not provide an expiration date.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
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.
POC: The EHR system contains releases for specific entities and state what may be released IAW PA Code 255.5. The releases include whether the client is or is not in treatment, the prognosis of the client, the nature of the project, a brief description of the progress of the client and a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse. The Program Director will retrain staff on the requirements for releases and update the templates to include expiration dates which may be altered as the client's request; Clinical Assistant will review existing releases and update if necessary; Program Director will review new client's releases within one week of admittance to ensure compliance.
Anticipated Completion Date: Client #3 signed her release on August 28, 2018. Client #5 was discharged, but if she returns to treatment, all releases will be updated. All staff, admin and clinical, were retrained by the Program Director by September 21, 2018. Clinical Assistant will complete audit by October 15, 2018.
|
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:
|
Observations
The facility failed to provide documentation of a comprehensive treatment plan being developed with the client in client records # 5 and 7 and treatment began before the individualized comprehensive treatment plan had been developed in client records # 2, 3, and 4.
Client # 2 was admitted on February 21, 2018 and was still an active client at the time of the inspection. There was not a treatment plan developed with the client until June 5, 2018. A treatment plan update was due August 5, 2018 but had not been documented by the time of the inspection.
Client # 3 was admitted on May 17, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed on June 7, 2018. A treatment plan update was due on August 7, 2018 but had not been documented by the time of the inspection.
Client # 4 was admitted on December 20, 2017 and was still an active client at the time of the inspection. There was not a treatment plan developed with the client until August 16, 2018.
Client # 5 was admitted on October 25, 2017 and was discharged on June 29, 2018. There was no documentation of a comprehensive treatment plan in the client record.
Client # 7 was admitted on October 12, 2017 and was discharge on July 23, 2018. There was no documentation of a comprehensive treatment plan in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
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: (1) Short and long-term goals for treatment as formulated by both staff and client. (2) Type and frequency of treatment and rehabilitation services (3) Proposed type of support service.
POC: Clinical Director will assume more intensive direct oversight of treatment planning. This will come in the form of a clinical staff meeting w/ therapists at the beginning of each month. This meeting will review new patients for target dates for master treatment planning (if not already completed) and target dates for treatment plan updates. The meeting will also review content of treatment planning to ensure that each is individualized & pertinent to patient's treatment needs to include short and long term goals, type and frequency of services and options for support services.
Anticipated Completion Date: First oversight meeting was held on September 17, 2018 and the next meeting is October 1 and will be held the first Monday of the month going forward (Thursday if Monday is a holiday).
|
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.
|
Observations
The facility failed to provide documentation of a treatment plan update every 60 days in 2 of 7 records reviewed.
Client # 2 was admitted on February 21, 2018 and was still an active client at the time of the inspection. There was not a treatment plan developed with the client until June 5, 2018. A treatment plan update was due August 5, 2018 but had not been documented by the time of the inspection.
Client # 3 was admitted on May 17, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed on June 7, 2018. A treatment plan update was due on August 7, 2018 but had not been documented by the time of the inspection.
|
Plan of Correction
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.
POC: Clinical Director will assume more intensive direct oversight of treatment planning. This will come in the form of a clinical staff meeting w/ therapists at the beginning of each month. This meeting will review new patients, set target dates for treatment plan updates and review existing patients to ensure updates are completed as scheduled. The meeting will also review content of treatment planning to ensure that each is individualized & pertinent to patient's treatment needs. In addition, Clinical Director & Program Director will utilize our EHR to send alerts to individual clinicians to inform them when a treatment plan/update is due on an individual patient.
Anticipated Completion Date: First oversight meeting was held on September 17, 2018 and the next meeting is October 1 and will be held the first Monday of the month going forward (Thursday if Monday is a holiday).
|