INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 11, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Renew Family Services, 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:
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Plan of Correction
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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.
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Observations
Based on a review of personnel records during the onsite inspection, the records contained no documentation of fire extinguisher or fire safety training for any of the three personnel reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By June 5, 2017, the staff that currently work at Renew Family Services will be trained by the Project Director, which will be reflected by a signed document with instructions. All future employees will be trained by the Project Director on how to use the fire extinguisher. The document will be signed and dated then filed in employee's folders as proof of the training.
This issue will no longer occur because if the Project Director is not available for training they will direct another point person such as a senior staff member to take the responsibility to train a new employee within the first month. All Renew Family staff are aware that new employees MUST be trained and MUST sign a document explaining the proper protocol in order to ensure fire safety on the premises. |
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 the review of seven client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client record # ' s 2, 3, 4, 5, 6, and 7. Additionally, client record # ' s 4, 6, and 7 had consent to release forms that were missing the purpose of the disclosure.
Client #2 was admitted on 10/20/16 and was still an active client at the time of the inspection. The record did not contain a consent to release information form for the funding source at the time of the inspection and there was evidence of disclosure of information.
Client #3 was admitted on 08/10/16 and was still an active client at the time of the inspection. The record did not contain a consent to release information form for the funding source at the time of the inspection and there was evidence of disclosure of information.
Client #4 was admitted on 12/08/16 and was still an active client at the time of the inspection. The record did not contain a consent to release information form for the funding source at the time of the inspection and there was evidence of disclosure of information. Additionally, consent to release information forms to family members, signed and dated 12/16/16 and 02/20/17, and a housing provider, signed and dated 03/27/17, failed to include the purpose of the disclosure.
Client #5 was admitted on 11/17/16 and was still an active client at the time of the inspection. The record did not contain a consent to release information form for the funding source at the time of the inspection and there was evidence of disclosure of information.
Client #6 was admitted on 01/06/17 and was still an active client at the time of the inspection. The record did not contain a consent to release information form for the funding source at the time of the inspection and there was evidence of disclosure of information. Additionally, a consent to release information form to another treatment provider, signed and dated 01/05/17, failed to include the purpose of the disclosure.
Client #7 was admitted on 01/07/17 and was still an active client at the time of the inspection. The record did not contain a consent to release information form for the funding source at the time of the inspection and there was evidence of disclosure of information. Additionally, consent to release information forms to a probation officer, signed and dated 03/30/17, and a family member, signed and dated 03/07/17, failed to include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2, 3, 4, 6, and 7 releases will be updated by June 2, 2017 by their therapist. Each release will define the purpose of the disclosure.
Client #5 releases will be updated once they are back from inpatient treatment. The release will specify the purpose of the disclosure.
All staff will be made aware how to properly fill out the releases in order to ensure that this deficiency does not occur again by Project Director or another senior staff. |
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.
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Observations
Based on a review of seven client records, client record # ' s 2, 3, and 5 lacked documentation verifying written acknowledgement by clients that they had been notified of the client rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will have clients #2 and 3 sign clients rights by no later than 6/5/17.
Client #5 will sign once they return from the inpatient level of care.
The Project Director has all new clients signing a packet of forms that includes the clients' rights to ensure this Add to deficiency doesn't reoccur. Also, the new EMR has it included as well so when new clients who have email can be sent the packets online which include the client's rights as well as other consent forms. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of seven client records, the facility failed to include documentation that a complete medical history was obtained in client record #'s 3, 4, and 7, during the intake and admission process. Additionally, the facility failed to include documentation of a drug and alcohol or personal history in client record # ' s 2 and 3.
Client #2 was admitted on 10/20/16 and was an active client at the time of inspection.
Client #3 was admitted on 08/10/16 and was an active client at the time of inspection.
Client #4 was admitted on 12/08/16 and was an active client at the time of inspection.
Client #7 was admitted on 01/07/17 and was an active client at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2 and 3 were in the original EMR system that the lawyer is taking legal action to get the records for the project, which the Project Director is responsibility for this follow up. The drug and alcohol history is in that system.
Therapist will obtain this information by 6/5/17. If not, the biopsychosocial will be updated by therapist by 6/5/17.
Clients #3, 4, and 7 will have a completed medical history by 6/5/17 completed by the therapist.
The Project Director will try to ensure this does not occur again by requesting ever therapist to print notes two months prior to stop using an EMR system. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of seven client records, the facility failed to ensure that client record # ' s 2, 3, and 5 contained documentation of client signed consent to treatment.
Client #2 was admitted on 10/20/16 and was an active client at the time of inspection.
Client #3 was admitted on 08/10/16 and was an active client at the time of inspection.
Client #5 was admitted on 11/17/16 and was an active client at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Therapist will have clients #2 and 3 sign an updated consent to treatment no later than 6/5/17. The original ones are in the EMR that the lawyer is trying to obtain and plans to get through legal action, which may take longer than allotted time allowed.
Therapist will have client #5 sign a consent to treatment again once they return from inpatient treatment.
The Project Director will have therapists print all documents two months before leaving an EMR to ensure this issue does not occur again. |
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 a review of seven client records, the facility failed to include documentation of a psychosocial evaluation in client record #'s 2 and 3.
Client #2 was admitted on 10/20/16 and was an active client at the time of inspection.
Client #3 was admitted on 08/10/16 and was an active client at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director is in contact with her lawyer to attempt to get Renew Family Services records from the first EMR system which will take longer then the allotted time.
Therapist for client #2 and #3 will complete a biopsychosocial by 6/5/17 in order to be compliant with DDAP regulations.
To ensure this never happens again, Project Director will inform all staff two months prior if switching EMRs in order to allow 2 months for therapists to print all records.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of seven client records, client record #'s 3, 6, and 7 did not have individual and comprehensive treatment and rehabilitation plans in the client records.
Client #3 was admitted on 08/10/16 and was active client at the time of inspection.
Client #6 was admitted on 01/06/17 and was active client at the time of inspection.
Client #5 was admitted on 01/07/17 and was active client at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director is in contact with her lawyer to attempt to get Renew Family Services records from the first EMR system which will take more time than allotted.
All updated individual treatment plans will be available and updated by 6/5/17 for clients #3, 6, 7 whether the original records are obtained.
Client #5 currently is inpatient at a treatment facility so treatment plan was not updated due being in a higher level of care and therapist will note this in client's records. All updates will be made as soon as he returns to treatment.
Project Director will inform all staff two months ahead of time when switching EMRs so all notes can be printed so this issue does not occur again. |
709.93(a) 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:
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Observations
Based on a review of seven client records, the facility failed to provide a complete client record in client records # 1.
Client #1 was admitted on 12/18/16 and was discharged on 02/03/17. The client record did not contain any documentation of case consultation notes, follow-up information, or discharge summary as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client was referred by probation officer. Therapist was waiting to have contact with his probation officer before discharging him since client worked out-of-town a lot and would be gone for a month. Project Director noted that this is an unusual case and is not the norm for our clients.
Therapist did not want to prematurely discharge him. Therapist has since then, spoke to probation officer and discharged him as of April 13, 2017. Project Director is to oversee that this is completed in a timely matter.
Renew Family Services will give a client a maximum of two months to return to treatment if they leave town for their job before discharging them from the program if they have no contact.
The discharge summary will be completed by May 15, 2017 as well as all follow-up attempts by therapist. |
709.2(a) LICENSURE Subchapter A.General Provisions.Policy
709.2. Policy.
(a) Persons, partnerships and corporations, or other legal entities intending to provide drug and alcohol treatment services, shall first be licensed by the Department.
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Observations
An interview with staff was conducted during the licensing inspection. Based on the interview, Renew Family Services, LLC has implemented the prescription of Buprenorphine for maintenance purposes and the storage and prescription of Vivitrol for clients in the outpatient facility.
Renew Family Services, LLC is not licensed to provide or prescribe Buprenorphine or Vivitrol on an outpatient basis at this location.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director contacted Patricia De Leo on April 28, 2017 and left a message to inquire on how to add Buprenorphine and Vivitrol to Renew Family services' License. Project Director will complete as needed all licensing alerts regarding intake, referral, and evaluation to the license by 6/5/17. Project Director tried to contact Wenona Wake to find out if any other additions need to be made in order to be in compliance with state regulations as well.
Project Director will complete the documentation required. If it does not satisfy DDAP requirements, Renew Family Services will outsource the services to other companies. This will ensure that this deficiency does not occur again. |