INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 7, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, WES Corporation 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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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures regarding the confidentiality of client identity and records.
The facility policy and procedure manual stated that WES will protect the confidentiality of all information in its records at all stages of collection, use, storage, disclosure, and destruction.
Client #4 was admitted on April 3, 2024 and was discharged on April 18. 2024. There was a client-related pre-screen application, dated March 6, 2024, attached to the electronic record of a different client at the time of the inspection.
This is a repeat citation from the December 6, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff as part of the inspection process.
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Plan of Correction
The client-related pre-screen was removed from the record of client #4. Going forward, D&A staff will meet every week to client records to ensure confidentiality on all levels of record-keeping are
maintained.
The program support specialist and program director will be responsible for monitoring this.
This is effective 11/25/2024. |
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 a review of client records, the facility failed to document the name of a person, agency, or organization to whom a disclosure was to be made to on release of information forms in six of seven client records reviewed.
Client #2 was admitted on March 27, 2024 and was active at the time of the inspection. There were release of information forms to a physician, a probation and parole officer, a family member, and a school that were signed and dated by a witness on March 27, 2024; however, there was no name of the person, agency, or organization to whom the disclosure was to be made included on any of the release forms.
Client #3 was admitted on March 20, 2024 and was active at the time of the inspection. There was a release for information form to a physician signed and dated by the client on March 20, 2024; however, there was no name of the person, agency, or organization to whom the disclosure was to be made included on release form. Additionally, there was a release for information form to a legal office signed and dated by a witness on April 10, 2024; however, there was no name of the person, agency, or organization to whom the disclosure was to be made included on the release form.
Client #4 was admitted on April 3, 2024 and was discharged on April 18, 2024. There were release of information forms to a physician, an emergency contact, a family member, and a school that were signed and dated by the client on April 3, 2024; however, there was no name of the person, agency, or organization to whom the disclosure was to be made included on any of the release forms.
Client #5 was admitted on January 16, 2024 and was discharged on July 24, 2024. There were release of information forms to a physician, an emergency contact, and a probation and parole office that were signed and dated by the client on January 16, 2024; however, there was no name of the person, agency, or organization to whom the disclosure was to be made included on any of the release forms. Additionally, there was a release of information form to a legal office was signed and dated by a witness on January 29, 2024; however, there was no name of the person, agency, or organization to whom the disclosure was to be made included on any of the release forms.
Client #6 was admitted on February 1, 2024 and was discharged on November 5, 2024. There were release of information forms to a family member and a probation and parole office that were signed and dated by the client on February 5, 2024; however, there was no name of the person, agency, or organization to whom the disclosure was to be made included on any of the release forms.
Client #7 was admitted on September 10, 2024 and was discharged on October 8, 2024. There were release of information forms to a physician, an emergency contact, a family member, a school, and a probation and parole office that were signed and dated by the client on January 16, 2024; however, there was no name of the person, agency, or organization to whom the disclosure was to be made included on any of the release forms.
This is a repeat citation from the December 6, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program staff shall update the release of information forms of clients 2, 3, 4, 5, 6, 7 to include the name of a person, agency or organization to whom a disclosure was made. Going forward release of information forms shall be reviewed by program support staff immediately following intake to confirm that forms are filled out in completion.
The program case manager and program director will be responsible for monitoring this on a monthly basis.
This policy's effective date is 11/25/24. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to include the dated signature of the client on release of information forms in four of seven client records reviewed.
Client #1 was admitted on June 20, 2024 and was active at the time of the inspection. A release of information form to a funding source was signed and dated by a witness on June 20, 2024; however, there was no dated signature of the client included on the release form.
Client #2 was admitted on March 27, 2024 and was active at the time of the inspection. There were release of information forms to a physician, a probation and parole office, a family member, a school, and a funding source that were signed and dated by witnesses on March 27, 2024; however, there was no dated signature of the client included on any of the release forms. Additionally, there was a release of information form to a family member signed and dated by a witness on April 7, 2024; however, there was no dated signature of the client included on the release form.
Client #3 was admitted on March 20, 2024 and was active at the time of the inspection. A release of information form to a legal office was signed and dated by a witness on April 10, 2024; however, there was no dated signature of the client included on the release form.
Client #5 was admitted on January 16, 2024 and was discharged on July 24, 2024. A release of information form to a legal office was signed and dated by a witness on January 29, 2024; however, there was no dated signature of the client included on the release form.
This is a repeat citation from the January 27, 2022, January 30, 2023, and December 6, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program staff shall update release of information forms for clients 1, 2, 3 and 5 to include the dated signature. Going forward release of information forms shall be reviewed by program support staff immediately following intake and afterward on a monthly basis to confirm that forms are filled in in completion. The program case manager and program director will be responsible for monitoring this. Effective 11/25/24 |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to include the documentation of the type and frequency of treatment and rehabilitation services on the client's individual treatment and rehabilitation plan in two of six applicable client records reviewed.
Client #1 was admitted on June 20, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan, completed on June 24, 2024, did not include the type and frequency of treatment and rehabilitation services.
Client #2 was admitted on March 27, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan, completed on April 6, 2024, did not include the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Staff shall meet with clients 1 and 2 to update the treatment plan to include type of treatment and frequency of treatment and rehabilitation services. Director has met with clinical staff relating to missing information in treatment plans and how the type, duration, & frequency of treatment goals needs to be explicit and evident in future plans. The program therapists and program director will be responsible for monitoring this every month. Effective 12/25/24 |
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.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include the documentation of follow-up information, in one of two applicable client records reviewed.
Client #5 was admitted on January 16, 2024 and was discharged on July 24, 2024. There was no documentation of follow-up information in the client record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program support staff shall run a report of recent client discharges on a weekly basis and document follow up in the client chart. Team has agreed to an internal policy to ensure aftercare follow-up within 30 days from discharge. The program support specialist and case manager will be responsible for ensuring follow up is conducted. Effective 11/25/24. |
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.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were previously approved by the Department.
A plan of correction for ensuring the dated signature of the client was included on all release of information forms were submitted and approved by the Department for the January 27, 2022, January 30, 2023, and December 6, 2023, annual licensing inspections. Failing to document the dated signature of the client on release of information forms was again found to be a deficiency in the November 7, 2024, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WES Passages Program Director and Quality Management staff shall review records weekly to ensure that the dated signature of the client were included on all release of information forms. WES Quality Management shall complete a quarterly review to ensure that the department is in compliance with all corrective action plans. All active participants will receive updated ROIs in January 2025 with documented signatures, printed names, dates, and information to the person or entity the information is being released to. Effective 11/25/2024 |