INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 8-9, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Arkview Recovery Center 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
|
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
|
Observations
Based on a physical site inspection, the facility failed to provide individual paper towels or a mechanical dryer in the bathroom referred to as the "shower room".
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Facilities Manager has placed paper towels in the appropriate bathroom stall in the shower room. Additionally, the Facilities Manager and Compliance Coordinator met to formulate a plan for ensuring compliance moving forward. As a result, the Facilities Manager has added a line item on the Restroom Cleanliness log to include "ensure that there is a mechanical dryer or stocked paper towels". The restroom cleanliness log is completed twice per day by designated facility staff. For instances where a deficiency has been identified, a corrective action plan is required to be submitted to the Executive Director. |
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.
|
Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in twenty out of twenty records reviewed. The releases of information forms were to the funding source and permitted "H&P", nursing assessment, biopsychosocial, treatment plan and aftercare plan to be released.
Client #1 was admitted on May 9, 2022 and discharged on June 8, 2022. The release of information form was dated May 9, 2022.
Client #2 was admitted on May 9, 2022 and was still active at the time of the inspection. The release of information form was dated May 9, 2022.
Client #3 was admitted on May 3, 2022 and was still active at the time of the inspection. The release of information form was dated by the client on May 3, 2022.
Client #4 was admitted on May 10, 2022 and was still active at the time of the inspection. The release of information form was dated May 10, 2022.
Client #5 was admitted on May 2, 2022 and was still active at the time of the inspection. The release of information form was dated May 2, 2022.
Client #6 was admitted on March 14, 2022 and discharged on April 13, 2022. The release of information form was dated March 15, 2022.
Client #7 was admitted on February 4, 2022 and discharged on March 14, 2022. The release of information form was dated February 4, 2022.
Client #8 was admitted on June 7, 2022 and was still active at the time of the inspection. The release of information form was dated June 7, 2022.
Client #9 was admitted on June 7, 2022 and was still active at the time of the inspection. The release of information form was dated June 7, 2022.
Client #10 was admitted on May 10, 2022 and was discharged to a lower level of care on May 17, 2022. The release of information form was dated May 10, 2022.
Client #11 was admitted on December 29, 2021 and discharged on January 5, 2022. The release of information form was dated December 30, 2021.
Client #12 was admitted on March 3, 2022 and discharged on March 11, 2022. The release of information form was dated March 3, 2022.
Client #13 was admitted on May 23, 2022 and discharged on May 30, 2022. The release of information form was dated May 23, 2022.
Client #14 was admitted on March 21, 2022 and discharged on March 26, 2022. The release of information form was dated March 21, 2022.
Client #15 was admitted on March 18, 2022 and discharged on April 13, 2022. The release of information form was dated March 18, 2022.
Client #16 was admitted on January 29, 2022 and discharged on February 28, 2022. The release of information form was dated January 31, 2022.
Client #17 was admitted on March 12, 2022 and discharged on April 11, 2022. The release of information form was dated March 14, 2022.
Client #18 was admitted on May 1, 2022 and discharged on June 3, 2022. The release of information form was dated May 1, 2022.
Client #19 was admitted on December 23, 2021 and discharged on January 21, 2022. The release of information form was dated December 24, 2021.
Client #20 was admitted on January 7, 2022 and discharged on February 9, 2022. The release of information form was dated January 10, 2022.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Executive Director and Compliance Coordinator met to identify why the electronic medical record template was pulling the incorrect release of information form. It was identified that the form rules and permitted information to be released was conflicted with release of information to "Emergency Contact". The Compliance Coordinator corrected the form rules to reflect for "funding source", to identify the five permitted points of information to be released, within 4 PA Code 255.5. Specifically, (1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
To prevent the deficiency from recurring, the Compliance Coordinator and Executive Director have limited the access to users who can make adjustments to EMR templates. Additionally, the Compliance Coordinator has added the review of Release of Information to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
|
Observations
Based on the review of client records, the facility failed to document a completed consent to release information form that included a dated signature of witness in six out of twenty records reviewed.
Client #3 was admitted on May 3, 2022 and was still active at the time of the inspection. A release of information form to a funding source was signed by the client on May 3, 2022 and witness by the client on May 6, 2022.
Client #4 was admitted on May 10, 2022 and was still active at the time of the inspection. A release of information form to an employee leave management company was signed by the client on June 1, 2022 and did not have a witness signature.
Client #6 was admitted on March 14, 2022 and discharged on April 13, 2022. A release of information form to another treatment facility was signed by the client on April 12, 2022 and signed by a witness on April 8, 2022.
Client #7 was admitted on February 2, 2022 and discharged on March 14, 2022. A release of information form to anther treatment facility was signed by the client on March 10, 2022 and signed by a witness on March 15, 2022.
Client #10 was admitted on May 10, 2022 and discharged to a lower level of care on May 17, 2022. A release of information form to a family member was signed by the client on May 10, 2022 and signed by a witness on May 11, 2022.
Client #17 was admitted on March 12, 2022 and discharged on April 11, 2022. A release of information form to a therapist was signed by the client on April 8, 2022 and signed by a witness on April 6, 2022.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Executive Director and Compliance Coordinator met to identify why this deficiency was occurring. It was determined that staff training was the main component for the cause of the deficiency. As a result, all staff were trained on the proper completion of a release of information form, including that the witness signature must be completed immediately following the client signature.
To prevent the deficiency from recurring, the Compliance Coordinator has added the review of Release of Information to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
Based on a review of client records, the facility failed to notify clients that they shall retain civil rights and liberties except as provided by statue and no client may be deprived of a civil right solely by reason of treatment in twenty out of twenty records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Compliance Coordinator reviewed the EMR template and included the missing Client Rights, specifically, notifying clients that they shall retain civil rights and liberties except as provided by statue and no client may be deprived of a civil right solely by reason of treatment. All active clients have signed the revised Client Rights form as of July 1, 2022.
To prevent the deficiency from recurring, the Compliance Coordinator and Executive Director have limited the access to users who can make adjustments to EMR templates. Additionally, the Compliance Coordinator has added the review of Client Rights to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of client records, the facility failed to notify clients that they may not be discriminated against based on ethnicity, marital status, sexual orientation, handicap, or religion in twenty out of twenty records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Compliance Coordinator reviewed the EMR template and included the missing Client Rights, specifically, notifying clients that they may not be discriminated against based on ethnicity, marital status, sexual orientation, handicap, or religion in twenty out of twenty records reviewed. . All active clients have signed the revised Client Rights form as of July 1, 2022.
To prevent the deficiency from recurring, the Compliance Coordinator and Executive Director have limited the access to users who can make adjustments to EMR templates. Additionally, the Compliance Coordinator has added the review of Release of Information to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. |
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.
|
Observations
Based on a review of client records, the facility failed to notify clients that the director may temporarily remove portions of their record prior to the inspection by the client and reasons for removing sections shall be documented in twenty out of twenty records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Compliance Coordinator reviewed the EMR template and included the missing Client Rights, specifically, notifying clients that the director may temporarily remove portions of their record prior to the inspection by the client and reasons for removing sections shall be documented in twenty out of twenty records reviewed.
All active clients have signed the revised Client Rights form as of July 1, 2022.
To prevent the deficiency from recurring, the Compliance Coordinator and Executive Director have limited the access to users who can make adjustments to EMR templates. Additionally, the Compliance Coordinator has added the review of Release of Information to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. |
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.
|
Observations
Based on a review of client records, the facility failed to notify clients that they have the right to appeal a decision limiting access to their records in twenty out of twenty records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Compliance Coordinator reviewed the EMR template and included the missing Client Rights, specifically, notifying clients that they have the right to appeal a decision limiting access to their records in twenty out of twenty records reviewed. All active clients have signed the revised Client Rights form as of July 1, 2022.
To prevent the deficiency from recurring, the Compliance Coordinator and Executive Director have limited the access to users who can make adjustments to EMR templates. Additionally, the Compliance Coordinator has added the review of Release of Information to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. |
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.
|
Observations
Based on a review of client records, the facility failed to notify clients that they have the right to request correction of inaccurate, irrelevant, outdated or incomplete information in their records in twenty out of twenty records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Compliance Coordinator reviewed the EMR template and included the missing Client Rights, specifically, notifying clients that they have the right to request correction of inaccurate, irrelevant, outdated or incomplete information in their records. All active clients have signed the revised Client Rights form as of July 1, 2022.
To prevent the deficiency from recurring, the Compliance Coordinator and Executive Director have limited the access to users who can make adjustments to EMR templates. Additionally, the Compliance Coordinator has added the review of Release of Information to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. |
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.
|
Observations
Based on a review of client records, the facility failed to notify clients that they have the right to submit rebuttal data or memoranda to their record in twenty out of twenty records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Compliance Coordinator reviewed the EMR template and included the missing Client Rights, specifically, notifying clients that they have the right to submit rebuttal data or memoranda to their record. All active clients have signed the revised Client Rights form as of July 1, 2022.
To prevent the deficiency from recurring, the Compliance Coordinator and Executive Director have limited the access to users who can make adjustments to EMR templates. Additionally, the Compliance Coordinator has added the review of Release of Information to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on a review of facility records, the facility failed to inform the Department of two unusual incidents within the required three days. It was discovered that the facility has unusual incidents involving ambulance presence on January 19, 2022 and January 29, 2022 that were not reported to the Department.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Executive Director and Compliance Coordinator met to identify the root cause of the unreported incidents. It was determined that although the facility has a process for identifying and reporting on unusual incidents, the staff required additional training on documenting and reporting unusual incidents. Appropriate staff were trained by way of team meetings. Additionally, the Executive Director and Compliance Coordinator have added a monthly review of incident reports as a standing agenda item to the monthly Quality Assurance and Performance Improvement Committee meeting to ensure compliance moving forward. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in three out of six records reviewed.
Client #15 was admitted on March 18, 2022 and discharged on April 13, 2022. The comprehensive treatment plan dated March 23, 2022 indicated weekly individual sessions. The client did not receive any individual sessions during the week of March 27-April 2, 2022.
Client #17 was admitted on March 12, 2022 and discharged on April 11, 2022. The comprehensive treatment plan dated March 12, 2022 indicated individual sessions "1-2x" per week. The client did not receive any individual sessions during the weeks of March 13-19, March 20-26, and March 27-April 2, 2022.
Client #18 was admitted on May 1, 2022 and discharged on June 3, 2022. The comprehensive treatment plan dated May 7, 2022 indicated individual sessions weekly. The client did not receive any individual sessions during the weeks of May 8-14, and May 22-28, 2022.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Executive Director, Clinical Supervisor and Compliance Coordinator collaborated to determine the cause of the deficiencies and not following the frequency of services outlined on the Individual Treatment Plan. It was identified that although the staff were conducting the individual sessions, the documentation template that was being used, did not allow for documenting of the session content. The team identified that this was an EMR issue and as of 7/1/22, the EMR template was revised to include the Individual Session content. All staff responsible for providing and documenting individual sessions have been trained on the revised form by way of staff meetings.
To prevent the deficiency from recurring, the Compliance Coordinator has added the review of treatment plan service frequencies to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. The results of the review are reported by the Clinical Supervisor to the QA Committee. If an instance of non-compliance is identified, a corrective action plan must be submitted to the Executive Director. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
|
Observations
Based on a review of client records, the facility failed to provide individual counseling at least twice weekly in five out of six applicable records.
Client #15 was admitted on March 18, 2022 and discharged on April 13, 2022. The client did not receive individual counseling sessions twice a week during their admission at the facility.
Client #16 was admitted on January 29, 2022 and discharged on February 28, 2022. The client did not receive individual counseling sessions twice a week between January 30 - February 5, 2022, and February 13-19, 2022.
Client #17 was admitted on March 12, 2022 and discharged on April 11, 2022. The client did not receive individual counseling sessions twice a week during their admission at the facility.
Client #18 was admitted on May 1, 2022 and discharged on June 3, 2022. The client did not receive individual counseling sessions twice a week during their admission at the facility.
Client #20 was admitted on January 7, 2022 and discharged on February 9, 2022. The client did not receive individual counseling sessions twice a week between January 9-15, 2022, and January 23 - February 9, 2022.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Executive Director, Clinical Supervisor and Compliance Coordinator collaborated to determine the cause of the deficiencies and providing individual counseling sessions at least twice per week for PHP clients. It was identified that although the staff were conducting the individual sessions, the documentation template that was being used, did not allow for documenting of the session content. The team identified that this was an EMR issue and as of 7/1/22, the EMR template was revised to include the Individual Session content. All staff responsible for providing and documenting individual sessions have been trained on the revised form by way of staff meetings.
To prevent the deficiency from recurring, the Compliance Coordinator has added verification of two individual counseling sessions per week, to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. The results of the review are reported by the Clinical Supervisor to the QA Committee. If an instance of non-compliance is identified, a corrective action plan must be submitted to the Executive Director. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in two out of three applicable records reviewed.
Client #11 was admitted on December 29, 2021 and discharged on January 5, 2022.
Client #12 was admitted on March 3, 2022 and discharged on March 11, 2022.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Executive Director, Compliance Coordinator and Clinical Supervisor met to discuss why Discharge Summaries are not being completed, according to company policy. The team identified that the staff responsible for documenting Discharge Summaries required additional training. All applicable staff were trained on the guidelines for completion of Discharge Summaries.
To prevent the deficiency from recurring, the Compliance Coordinator has added the review of Discharge Summary to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. The results of the review are reported by the Clinical Supervisor to the QA Committee. If an instance of non-compliance is identified, a corrective action plan must be submitted to the Executive Director. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in four out of seven records reviewed.
Client #3 was admitted on May 3, 2022 and was still active at the time of the inspection. The comprehensive treatment plan dated May 10, 2022 indicated one individual session per week. The record of service and progress notes indicated that the client did not have an individual session during the week of May 15 - 21, 2022.
Client #4 was admitted on May 10, 2022 and was still active at the time of the inspection. The comprehensive treatment plan dated May 10, 2022 indicated one individual session per week. The record of service and progress notes indicated that the client did not have an individual session during the week of May 29- June 4, 2022.
Client #5 was admitted on May 2, 2022 and was still active at the time of the inspection. The comprehensive treatment plan dated May 12, 2022, indicated one individual session per week. The record of service and progress notes indicated that the client did not have an individual session during the week of May 22-28, 2022.
Client #7 was admitted on February 4, 2022 and discharged on March 14, 2022. The comprehensive treatment plan dated February 11, 2022 indicated individual sessions "2-4x" per week. The record of service and progress notes indicated that the client did not have any individual sessions during the week of February 20-26, 2022.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Executive Director, Clinical Supervisor and Compliance Coordinator collaborated to determine the cause of the deficiencies and not following the frequency of services outlined on the Individual Treatment Plan. It was identified that although the staff were conducting the individual sessions, the documentation template that was being used, did not allow for documenting of the session content. The team identified that this was an EMR issue and as of 7/1/22, the EMR template was revised to include the Individual Session content. All staff responsible for providing and documenting individual sessions have been trained on the revised form by way of staff meetings.
To prevent the deficiency from recurring, the Compliance Coordinator has added the review of treatment plan service frequencies to the Clinical Chart Audit Tool, where a random sampling of 20% of active charts are reviewed on a monthly basis to ensure ongoing compliance. The results of the review are reported by the Clinical Supervisor to the QA Committee. If an instance of non-compliance is identified, a corrective action plan must be submitted to the Executive Director. |