INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19-20, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Valley View Health Services 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:
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Plan of Correction
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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 fire drill log for the months of January 2024 through August 2024, the facility failed to maintain a written fire drill record including documentation of the exit route used in all fire drill logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The audit showed that our fire drill log needed to be corrected. The clinical supervisor has created a new fire drill log that includes a space to identify which door was used in every fire drill.
The person conducting the fire drill will rotate which door is used each time they drill. Door #1 or Door #2 will be indicated in the log moving forward. These changes will be implemented by 11-30-2024.
This will be inspected by the program director monthly to ensure that proper documentation is being completed. a signature page has been added to the log. The program will initial and date this demonstrating that they have checked the fire drill log and that all of these protocols are being followed. |
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 applicable client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in two of four records.
Client #1 was admitted on February 2, 2024 and was discharged on July 2, 2024. The client record contained a consent form signed on January 31, 2024 that did not include the name of person, agency or organization to whom the disclosure is made, specific information to be disclosed, the purpose of disclosure, and date, event, or condition upon which the consent will expire.
Client #3 was admitted on February 6, 2024 and was still active at the time of the inspection. The client record contained a consent form signed on February 5, 2024 that did not include the name of person, agency or organization to whom the disclosure is made, and specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will create consent form and this will become part of a new client handbook, which will be given to every client upon admission.
This new consent form will be completed, if the release of information is requested by the client.
This form will include the name of the person, agency or organization who information is to be released to.
This form will also include the specific information released and for what purpose.
These new consent forms will be standard in every client handbook provided at admission. The program director will inspect the client handbook by the clients 2nd session to ensure that the implied consent form is completed correctly. This will be implemented by 11-30-2024. |
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 applicable client records reviewed, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on the signed consent forms in two of four records.
Client #1 was admitted on February 2, 2024 and was discharged on July 2, 2024. An informed and voluntary consent was signed and dated January 31, 2024, but did not include the name of the person, agency, or organization to whom disclosure is made.
Client #3 was admitted on February 6, 2024 and was still active at the time of the inspection. An informed and voluntary consent was signed and dated February 5, 2024, but did not include the name of the person, agency, or organization to whom disclosure is made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will create consent form and this will become part of a new client handbook, which will be given to every client upon admission.
This new consent form will be completed, if the release of information is requested by the client.
This form will include the name of the person, agency or organization who information is to be released to.
This form will also include the specific information released and for what purpose.
These new consent forms will be standard in every client handbook provided at admission. The program director will inspect the client handbook by the clients 2nd session to ensure that the implied consent form is completed correctly. This will be implemented by 11-30-2024. |
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 applicable client records reviewed, the facility failed to document the specific information disclosed on the signed consent forms in two of four records.
Client #1 was admitted on February 2, 2024 and was discharged on July 2, 2024. An informed and voluntary consent was signed and dated January 31, 2024, but did not include the specific information disclosed.
Client #3 was admitted on February 6, 2024 and was still active at the time of the inspection. An informed and voluntary consent was signed and dated February 5, 2024, but did not include the specific information disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will create consent form and this will become part of a new client handbook, which will be given to every client upon admission.
This new consent form will be completed, if the release of information is requested by the client.
This form will include the name of the person, agency or organization who information is to be released to.
This form will also include the specific information released and for what purpose.
These new consent forms will be standard in every client handbook provided at admission. The program director will inspect the client handbook by the clients 2nd session to ensure that the implied consent form is completed correctly. This will be implemented by 11-30-2024. |
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 applicable client records reviewed, the facility failed to document the purpose of the disclosure on the signed consent forms in two of four records.
Client #1 was admitted on February 2, 2024 and was discharged on July 2, 2024. An informed and voluntary consent was signed and dated January 31, 2024, but did not include the purpose of the disclosure.
Client #3 was admitted on February 6, 2024 and was still active at the time of the inspection. An informed and voluntary consent was signed and dated February 5, 2024, but did not include the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will create consent form and this will become part of a new client handbook, which will be given to every client upon admission.
This new consent form will be completed, if the release of information is requested by the client.
This form will include the name of the person, agency or organization who information is to be released to.
This form will also include the specific information released and for what purpose.
These new consent forms will be standard in every client handbook provided at admission. The program director will inspect the client handbook by the clients 2nd session to ensure that the implied consent form is completed correctly. This will be implemented by 11-30-2024. |
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 applicable client records reviewed, the facility failed to document the date, event, or condition upon which the consent will expire on the signed consent forms in one of four records.
Client #1 was admitted on February 2, 2024 and was discharged on July 2, 2024. An informed and voluntary consent was signed and dated January 31, 2024, but did not include the date, event, or condition upon which the consent will expire.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will create consent form and this will become part of a new client handbook, which will be given to every client upon admission.
This new consent form will be completed, if the release of information is requested by the client.
This form will also include an expiration date for when the consent ends
These new consent forms will be standard in every client handbook provided at admission.
The program director will inspect the client handbook by the clients 2nd session to ensure that the implied consent form is completed correctly. This will be implemented by 11-30-2024. |
709.30 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.
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Observations
Based on applicable client records reviewed, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their rights in four of four records.
Client #1 was admitted on February 2, 2024 and was discharged on July 2, 2024. There was not written acknowledgment by the client in their record.
Client #2 was admitted on February 2, 2024 and was still active at the time of the inspection. There was not written acknowledgment by the client in their record.
Client #3 was admitted on February 6, 2024 and was still active at the time of the inspection. There was not written acknowledgment by the client in their record.
Client #4 was admitted on February 11, 2024 and was still active at the time of the inspection. There was not written acknowledgment by the client in their record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will implement a new form titled TREATMENT CONTRACT that will provide documentation / written acknowledgement by the client that the client has been made aware of their rights.
The clients signature will indicate that they have been made aware of these rights and their signature will demonstrate their acknowledgement that they have been made aware of their rights.
These rights will be clearly spelled out in the treatment contract form and added to the client handbook.
This will be added to and given to every client at admission and implemented inspected by the program director to ensure that each clients signs demonstrates that they are aware of their rights.
This will be implemented by 11-30-2024 |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure to the client of criteria for admission, treatment, completion, and discharge in three of four records.
Client #1 was admitted on February 2, 2024 and was discharged on July 2, 2024.
Client #3 was admitted on February 6, 2024 and was still active at the time of the inspection.
Client #4 was admitted on February 11, 2024 and was still active at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Director will create a new form titled "Admission / Discharge Form".This form will disclose all information about criteria for admission, treatment, completion and discharge.
This will include criteria for successful and unsuccessful discharge.
The Project Director will ensure that all Intake assessments will clearly state criteria for admission and referral to OP 1.0 LOC.
This form will be added to every client handbook and given to every client at admission. The client will be required to sign the form acknowledging that they are aware of the treatment expectations.
The Project Director will check to ensure that this form is signed and that the client is aware of the treatment expectations before starting treatment in the 1.0 LOC.
This new form will be implemented by 11-30-2024 and inspected by the Project Director to ensure this is completed |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document that client orientation to the project which included a familiarization with project policies in three of four records.
Client #1 was admitted on February 2, 2024 and was discharged on July 2, 2024.
Client #3 was admitted on February 6, 2024 and was still active at the time of the inspection.
Client #4 was admitted on February 11, 2024 and was still active at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Director will create a new form and add it to the client handbook.
This form will be titled, "Treatment Contract" and it will include orientation information, helping the client to understand the program policies and expectations.
The client will sign at admission / first session demonstrating that they were made aware of the expectations and policies of the program.
The Program Director will inspect the Client Handbook to ensure that the client was administered the Treatment contract and signed it at admission.
The Clinical Supervisor will implement by 11-30-2024. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document that client orientation to the project which included a familiarization with hours of operation in three of four records.
Client #1 was admitted on February 2, 2024 and was discharged on July 2, 2024.
Client #3 was admitted on February 6, 2024 and was still active at the time of the inspection.
Client #4 was admitted on February 11, 2024 and was still active at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Director will create a new form and add it to the client handbook.
This form will be titled, "Treatment Contract" and it will include; the programs hours of operation at Valley View.
The client will sign at admission / first session demonstrating that they were made aware of the hours of operation.
The Program Director will inspect the Client Handbook to ensure that the client was administered the Treatment contract and signed it at admission.
The Clinical Supervisor will implement by 11-30-2024. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document that client orientation to the project which included a familiarization with fee schedules in three of four records.
Client #1 was admitted on February 2, 2024 and was discharged on July 2, 2024.
Client #3 was admitted on February 6, 2024 and was still active at the time of the inspection.
Client #4 was admitted on February 11, 2024 and was still active at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Director will create a new form and add it to the client handbook.
This form will be titled, "Financial Form" and it will include information about fees, benefits and financial obligations of the client.
The client will sign at admission / first session demonstrating that they were made aware of the fees, benefits and financial obligations.
The Program Director will inspect the Client Handbook to ensure that the client was administered the Financial Forms and signed it at admission.
The Clinical Supervisor will implement by 11-30-2024. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to document that client orientation to the project which included a familiarization with services provided in three of four records.
Client #1 was admitted on February 2, 2024 and was discharged on July 2, 2024.
Client #3 was admitted on February 6, 2024 and was still active at the time of the inspection.
Client #4 was admitted on February 11, 2024 and was still active at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Director will create a new form and add it to the client handbook.
This form will be titled, "Treatment Contract" and it will include orientation information, helping the client to understand the program policies and expectations. The expectation will state the times and days of the week that we are open and what services are available to them through our program.
The client will sign at admission / first session demonstrating that they were made aware of the expectations and policies of the program.
The Program Director will inspect the Client Handbook to ensure that the client was administered the Treatment contract and signed it at admission.
The Clinical Supervisor will implement by 11-30-2024. |
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 the review of client records, the facility failed to document a psychosocial evaluation in two of four applicable records.
The facility ' s policy and procedure manual states the psychosocial evaluation must be completed within seven days of admission.
Client #2 was admitted on February 2, 2024 and was still active at the time of the inspection.
Client #4 was admitted on February 11, 2024 and was still active at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Moving forward the Clinical Supervisor will be responsible for completing a Psychosocial evaluation.
This will be completed by the therapist or clinical supervisor within 7 days of admission.
The Project Director will inspect to ensure that this is done and completed.
These new policy changes will be implemented by they Clinical Supervisor and all new clients will be given a psychosocial evaluation within 7 days of admission beginning on or before 11-30-2024. |