INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 18, 2023 through January 19, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Recovery Center, LLC 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
|
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
|
Observations
Based on a review of personnel records, the facility failed to provide documentation that a counselor assistant is supervised by a full-time clinical supervisor or counselor in one of one applicable personnel record reviewed.
Employee # 7 was hired as a counselor assistant on September 3, 2022. There were no supervision notes documented in the record from the date hired through the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer and Clinical Supervisor have already begun documenting the ongoing clinical supervisor for Employee #7, a Counselor's Assistant (CA). The Clinical Supervisor will meet with Employee #7 and any future CAs for 2 sixty minute supervisions per week in the following domains:(i) Client recordkeeping. (ii) Confidentiality. (iii) Pharmacology. (iv) Treatment planning. (v) Counseling techniques. (vi) Drug and alcohol assessment. (vii) Codependency. (viii) Adult Children of Alcoholics (ACOA) issues. (ix) Disease of addiction. (x) Aftercare planning. (xi) Principles of Alcoholics Anonymous and Narcotics Anonymous. (xii) Ethics. (xiii) Substance abuse trends. (xiv) Interaction of addiction and mental illness. (xv) Cultural awareness. (xvi) Sexual harassment.(xvii)Developmental psychology. (xviii)
Relapse prevention.
The Clinical Supervisor and CA will sign off on each supervisor session and indicate which domains were covered during the supervision. The documented evidence of supervision will be kept in a 3-ring binder in the Clinical Supervisor's office and reviewed by Chief Clinical Officer monthly. |
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure that a counselor assistant documented to the facility director that they are working toward counselor status upon the completion of each calendar year in one of one applicable personnel record reviewed.
Employee # 7 was hired as a counselor assistant on September 3, 2022. The documentation that the employee is working towards counselor status was due to be completed by December 31, 2022; however, there was no status documentation in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer sent an email to the Counselor Assistant on 2/1/23 with the citation for this regulation and requested documentation for evidence that she is working toward becoming a credentialed counselor within the required timeframe. The CA acknowledged the email and stated she will comply within the 5 business days to submit the required documentation. Moving forward, the Chief Clinical Supervisor will include this documentation for the current CA and all future CAs in the audit that will be reviewed weekly in the DDAP Compliance Management Meetings. |
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
|
Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a comprehensive staff development program for agency personnel, which is to include policies and procedures for the program indicating who is responsible and the time frames for completion for the following components: an assessment of staff training needs, an overall plan for addressing those needs, a mechanism to collect feedback on completed trainings, and an annual evaluation of the overall training plan.
This is a repeat citation from the January 13, 2022 and January 12, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
04.11 (a) Plan of Correction: Chief Clinical Officer will develop, in collaboration with all staff members, an annual training plan that must be completed within the annual training timeframe. The training plan must include at least 25 hours of training for clinical staff and appropriate trainings for support staff, each signed off on by both the Chief Clinical Officer, support supervisor if needed, and staff member respective of their individualized plan. The training plan will be reviewed for progress at each weekly DDAP Compliance Management Meeting. Clinical staff members assume full responsibility to earn hourly trainings (min. of 25) within the established time-frame to uphold the plan of correction and policy and procedure outlining annual clinical staff trainings. All staff will provide documentation/ certification of completion for trainings outlined in annual training plan, which will be placed in employee file. This regulation will be added to PARC's Policies and Procedures as a requirement for all clinical staff, job requirements. This update will occur by 02/01/2023. Staff must complete their required trainings by 12/29/2023. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of personnel records, the facility failed to ensure that a written individual training plan, to be developed annually with input from both the employee and the supervisor, was documented in eleven of twelve applicable personnel records reviewed.
Employee # 1 was hired as the project director on December 23, 2019. There was no individual training plan completed at the time of the inspection.
Employee # 2 was hired as a clinical supervisor on February 3, 2020. There was no individual training plan completed at the time of the inspection.
Employee # 3 was hired as a counselor on August 25, 2020. The last individual training plan in the record was completed on February 11, 2021.
Employee # 4 was hired as a counselor on July 15, 2021. The individual training plan was completed on January 30, 2022; however, there was no documentation that the plan was completed with input from the supervisor.
Employee # 6 was hired as a counselor on May 16, 2019. The last individual training plan in the record was completed on February 11, 2021.
Employee # 7 was hired as a counselor assistant on September 3, 2022. There was no individual training plan completed at the time of the inspection.
Employee # 8 was hired as the Chief of Operations on November 1. 2021. There was no individual training plan completed at the time of the inspection.
Employee # 9 was hired as the Director of Admissions on May 16, 2019. There was no individual training plan completed at the time of the inspection.
Employee # 10 was hired as the UR Specialist on August 29, 2022. There was no individual training plan completed at the time of the inspection.
Employee # 11 was hired as a BHT on February 14, 2022. There was no individual training plan completed at the time of the inspection.
Employee # 12 was hired as a BHT on August 11, 2022. There was no individual training plan completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction: Chief Clinical Officer will develop, in collaboration with all staff members, an annual training plan that must be completed within the annual training timeframe 2/1/23-12/29/23. The training plan must include at least 25 hours for clinical staff and include required trainings for support staff based on need. This plan will be agreed upon, signed off on by both the Chief Clinical Officer, support supervisor if needed, and each staff member respective of their individualized plan. The training plans will be reviewed for progress at each weekly DDAP Compliance Management Meeting. Clinical staff members assume full responsibility to earn hourly trainings (min. of 25) within the established time-frame to uphold the plan of correction and policy and procedure outlining annual clinical staff trainings. All staff will provide documentation/ certification of completion for these trainings, which will be placed in employee file. This regulation will be added to PARC's Policies and Procedures as a requirement for all clinical staff, job requirements. This update will occur by 02/01/2023.. Staff must complete their required trainings by 12/31/2022 |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in four of six applicable personnel records.
Employee #1 was hired as the project/facility director on December 23, 2019. The HIV/AIDS and TB/STD trainings were due to be completed no later than December 23, 2021. Both the HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee #3 was hired as a counselor on August 25, 2020. The HIV/AIDS and TB/STD trainings were due to be completed no later than August 25, 2021. Both the HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee #5 was hired as a counselor on October 14, 2020. The HIV/AIDS and TB/STD trainings were due to be completed no later than October 14, 2021. However, the HIV/AIDS training was not completed until December 25, 2022 and the TB/STD training was not completed until December 16, 2022.
Employee # 9 was hired as the director of admissions on May 16, 2019. The HIV/AIDS and TB/STD trainings were due to be completed no later than May 16, 2021. Both the HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
This is a repeat citation from the January 13, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer has identified a 30 day training window for all indicated staff/ employees to be fully trained in 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics. Employees 1, 3, 5, & 9 have been informed that they will have until 3/1/2023 to complete the outstanding and required trainings. The certificates for training completions will be placed in the respective employee files and all current and future employee files will be reviewed in the weekly DDAP Compliance Management Meetings. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of personnel records, the facility failed to ensure that each clinical supervisor completed at least 12 clock hours of training, during the facility's January 1, 2022 through December 31, 2022 training year, in one of one applicable personnel record reviewed.
Employee #2 was hired as a clinical supervisor on February 3, 2020. The personnel record documented 9 hours of training for the reviewed period.
This is a repeat citation from the January 13, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer will review the progress of all annual training plans for employees at weekly DDAP Compliance Management Meetings. All staff will develop and sign their annual training plans with the Chief Clinical Officer and immediate supervisor if needed.Annual training plans will be from 2/1/2023-12/29/2023. Existing employees and all future employees will have their respective employee file and training plan reviewed as part of the weekly DDAP Compliance Management Meetings to properly gauge employee progress and timeframes. The Chief Clinical Officer will place employees on Corrective Action Plans if they begin to fall behind on their required training timeline. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training, during the facility's January 1, 2022 through December 31, 2022 training year, in two of four applicable personnel records reviewed.
Employee #3 was hired as a counselor on August 25, 2020. The personnel record documented 23.5 hours of training during the reviewed training year.
Employee #6 was hired as a counselor on May 16, 2019. The personnel record documented 21 hours of training during the reviewed training year.
This is a repeat citation from the January 13, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer will develop, in collaboration with all clinical staff an annual training plan that will require at least 25 hours of completed trainings that satisfy training needs. Chief Clinical Officer identified the annual training timeframe as 2/1/2023 to 12/29/23. Each clinical staff member can earn CEUs in the following domains: (i) Supervision and evaluation. (ii) Counseling techniques. (iii) Substance abuse trends and treatment methodologies in the field of addiction. (iv) Confidentiality. (v) Codependency/Adult Children of Alcoholics (ACOA) issues. (vi) Ethics. (vii) Interaction of addiction and mental illness. (viii) Cultural awareness. (ix) Sexual harassment. (x) Developmental psychology. (xi) Relapse prevention. (xii) Disease of addiction. (xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
All annual training plans for existing and new clinical employees will be reviewed at each weekly DDAP Compliance Management Meeting. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Based on a physical plant inspection, the facility failed to keep the facility safe and free from any danger to the safety and well-being of clients, employees, and visitors.
There was an exposed electrical box under the table in the conference room, which allowed for a possible electrical shock hazard.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer informed the CEO of the identified citation and potential safety risk posed by the exposed wires located under the table in the conference room. Upon inspection, the table was never connected, nor does it have an electrical cord any longer. To guarantee safety, the CEO placed a maintenance order to have the electrical box and wires removed ASAP. The facility's maintenance department assured removal by 2/3/2023. Moving forward, 'Facility safety' will be added to the weekly DDAP Compliance Management Meetings and all issues related to this domain will be reviewed and corrected as needed by management team. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in one of three applicable personnel records reviewed.
Employee # 12 was hired as a BHT on August 11, 2022. There was no documentation of training in the use of fire extinguishers at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer has updated all employee files with current fire extinguisher training, Employee #12 has completed fire extinguisher training and signed off on the completed training, documentation in employee file. Moving forward, as part of the weekly DDAP Compliance Management Meeting, 'Fire safety' will be included as an agenda item, reviewing all current and needed training for that domain and assuring all documentation related to the trainings are signed and located in the respective employee files. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of three applicable personnel records reviewed.
Employee # 12 was hired as a BHT on August 11, 2022. There was no documentation of emergency preparedness training at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer has updated all employee files to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Employee #12 has completed this training and signed off on the completed training documentation, which is located in the employee file. Moving forward, as part of the weekly DDAP Compliance Management Meeting, 'Emergency training, policies, and proceedure'' will be included as an agenda item, reviewing all current and needed training for that domain and assuring all documentation related to the trainings are signed and located in the respective employee files. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the facility's January 2022 through January 2023 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills for each monthly fire drill conducted during that timeframe. Every fire drill log, during the reviewed period, documented that the exit route used was through the front lobby doors.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer has informed Chief Operating Officer, who is responsible for conducting and documenting all fire/ emergency evacuation drills of the citation related to this regulation. COO will alternate exits each month and document the exist that was utilized in the 'Fire Drill Log' to satisfy this regulation. Moving forward, as part of the weekly DDAP Compliance Management Meeting, 'Fire safety' will be included as an agenda item, reviewing all regulations and corrective action if needed. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of the facility's January 2022 through January 2023 fire drill logs, the facility failed to ensure that a fire alarm or smoke detector was set off during each fire drill.
There was no documentation that a fire alarm or a smoke detector was set off during the January 2022 through May 2022 documented fire drills and the July 2022 through January 2023 documented fire drills.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer will submit a letter to DDAP requesting dispensation related to a facility fire alarm or smoke detector. The letter, which will be submitted by 2/23/23 will be asking for the allowance of an air-horn to simulate a fire alarm or smoke detector due to the facility being shared with multiple businesses. If approved, the utilization of an air-horn will be documented in the "Fire Drill Log"for each completed drill. If the request is not approved by DDAP, Chief Clinical Officer will meet with building management/ owner and local fire department to request utilization of building fire alarm during drills. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on an administrative review, the project director failed to prepare, annually update, and sign the written manual, which delineates the project's policies and procedures.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer will review and update (as needed) the project's Policy & Procedure Manual at each weekly DDAP Compliance Management Meeting. Chief Clinical Officer will sign the finalized version of the Policy & Procedures Manual at the final management meeting prior to the next DDAP inspection. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
|
Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
This is a repeat citation from the January 12, 2021 and January 13, 2022 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
CEO has notified the independent certified public accountant who was been retained to maintain financial records, taxes, audits, etc. that an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles, which include reference to the drug and alcohol treatment activities is due for fiscal year 2022. CPA has been notified to include previously missed audits for years prior to and including 2022. The independent CPA has notified the company it can take up to 60 days for the required audits to be completed and documentation submitted.
CEO will submit all outstanding fiscal audits to DDAP when they are received by CPA via email.
Moving forward CEO will request CPA to complete a fiscal audit within 6 months of the end of that fiscal year. Oour DDAP Compliance Management Team has included this regulation in its weekly meetings as a permanent agenda item that will be reviewed to assure this regulation is met during each subsequent inspection.
|
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in seven of fourteen client records reviewed.
Client # 6 was admitted to the partial hospitalization activity on October 7, 2022 and was discharged on November 21, 2022. There was evidence of disclosures to a laboratory on October 13, 2022, October 19, 2022, October 20, 2022, October 27, 2022, October 31, 2022, November 3, 2022, November 9, 2022, November 10, 2022 November 14, 2022, and November 17, 2022; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 7 was admitted to the partial hospitalization activity on April 19, 2022 and was discharged on June 15, 2022. There was evidence of disclosures to a laboratory on April 19, 2022, May 3, 2022, May 9, 2022, May 17, 2022, May 18, 2022, and May 31, 2022; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 8 was admitted to the outpatient activity on November 1, 2022 and was still active at the time of the inspection. The release of information form to a laboratory was signed by the client on September 20, 2022 and the form expired on December 19, 2022. A new release of information form was signed by the client on January 17, 2023; however, there was evidence of disclosures to the laboratory on December 27, 2022, after the first form expired and prior to the new form being signed.
Client # 9 was admitted to the outpatient activity on October 24, 2022 and was still active at the time of the inspection. The release of information form to a laboratory was signed by the client on September 14, 2022 and the form expired on December 13, 2022. A new release of information form was signed by the client on January 17, 2023; however, there was evidence of disclosures to the laboratory on December 27, 2022 and January 3, 2023, after the first form expired and prior to the new form being signed.
Client # 10 was admitted to the outpatient activity on November 22, 2022 and was still active at the time of the inspection. There was evidence of disclosures to a laboratory on November 25, 2022, November 28, 2022, and December 6, 2022; however, there was no consent to release information form signed by the client documented in the record until January 17, 2023.
Client # 12 was admitted to the outpatient activity on July 19, 2022 and was discharged on November 3, 2022. There was evidence of disclosures to a laboratory on July 21, 2022, July 27, 2022, August 2, 2022, August 10, 2022, August 15, 2022, August 31, 2022, September 7, 2022, September 21, 2022, September 26, 2022, October 17, 2022, and October 24, 2022; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 13 was admitted to the outpatient activity on July 28, 2022 and was discharged on November 10, 2022. There was evidence of disclosures to a laboratory on July 28, 2022, August 2, 2022, August 9, 2022, August 15, 2022, August 22, 2022, September 6, 2022, September 26, 2022, October 4, 2022, October 10, 2022, October 18, 2022, and October 25, 2022; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer informed the Chief Operating Officer and Director of Admissions to facilitate and/or train support/ admissions staff on the proper completion of informed and voluntary consent for release of confidential information to
These releases must be active for 365 days from signed consent, unless declined by the client
Moving forward, Chief Clinical Officer has included ROIs in weekly chart audits for compliance.
All active clients have signed updated ROIs for lab testing. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in fourteen of fourteen client records reviewed.
In every client record reviewed, there was no documentation, in the record, that a copy of each release of information form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer and Clinical Program Director have already updated all release of information consent templates in EMR to reflect and document informed discussion with client; informing them of their right to have a copy of any consent they sign for release of confidential information. All ROIs will be levied by Chief Clinical Officer during weekly charting audits to maintain compliance. |
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.
|
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 three of seven applicable client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on November 30, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 15, 2022; however, the plan did not include what the type and frequency of treatment and rehabilitation services were.
Client # 3 was admitted to the partial hospitalization activity on December 15, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 3, 2023; however, the plan did not include what the type and frequency of treatment and rehabilitation services were.
Client # 5 was admitted to the partial hospitalization activity on September 14, 2022 and was discharged on October 23, 2022. The individual treatment and rehabilitation plan was completed on October 5, 2022; however, the plan did not include what the type and frequency of treatment and rehabilitation services were.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer has already updated the EMR system, to include individualized type & frequency of services for the Master Treatment Plan Template. This will be a mandatory aspect of the individualized Master Treatment Plan for each client and will be included in the weekly compliance audit conducted by Chief Clinical Officer. Primary Therapists will update this aspect of the Master Treatment Plan for each client as they progress through the continuum of care, detailing type and frequency of clinical services. |
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 a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in two of four applicable client records reviewed.
Client # 13 was admitted to the outpatient activity July 28, 2022 and was discharged on November 11, 2022. The record did not include documentation of follow-up information as of the date of the inspection.
Client # 14 was admitted on August 22, 2022 and was discharged on December 5, 2022. The record did not include documentation of follow-up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer developed and implemented a new evidence-based tracking tool. The tool has already been built into our EMR system and is being utilized with each new client upon meeting with their Primary Therapist (PT). The PT will complete this tool within 72 hours of admission, then again at 2 weeks, again at 30 days, 60 days, 120 days upon discharge, and then 365 days after discharge. This process has already started and is part of the weekly auditing completed by Chief Clinical Officer to maintain compliance. |
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.
|
Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to develop a comprehensive staff development program for agency personnel, including policies and procedures for the program, was submitted and approved by the Department for the January 13, 2022 and January 12, 2021 annual licensing inspections. Failing to develop a comprehensive staff development program for agency personnel, including policies and procedures for the program, was again found to be a deficiency in the January 18, 2023 through January 19, 2023 licensing inspection.
A plan of correction for failing to complete an annual financial audit was submitted and approved by the Department for the January 13, 2022 and January 12, 2021 annual licensing inspections. Failing to complete an annual financial audit was again found to be a deficiency in the January 18, 2023 through January 19, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Chief Clinical Officer and Clinical Supervisor were briefed by DDAP Agent about the possibility of having our PA License 91C86601 changed to provisional due to repeated citations. WE take this potential consequence very seriously.
Chief Clinical Officer has established weekly meetings with the management team and ownership to address DDAP regulations, Status of Plans of Correction, Compliance, Updates to P & P, staff and facility training plans, etc. These weekly meetings are intended to provide an organized approach to and oversight of programmatic compliance with DDAP Regulations. The weekly meetings, participants, and agenda items will be documented and stored in a 3-ring binder, which will be located in the office of the Chief Clinical Officer. |