INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 1, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, American Treatment Network 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) (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.
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Observations
Based on a review of the facility's January 2021 through November 2021 fire drill logs, the facility failed to ensure that a fire alarm or a smoke detector was set off for every drill conducted during the reviewed period.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Target Date: 1/31/2022
Unfortunately, we rent the second floor of a building with multiple tenants. It is not plausible to activate the alarm with each fire drill.
To resolve this issue, by the target date listed above, we will apply for a waiver to this standard. If this waiver is denied, we propose the following:
By 1/31/2022, we will work with the ownership of the building and the other tenants to operate a monthly fire drill on a set schedule, that include activation of the alarm. This process will be much more difficult given that two of the other tenants are groups working with people with significant physical impairments (Physical therapy office and a day program for autistic children. |
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 a review of client records, the facility failed to complete an informed and voluntary consent to release information form to each client ' s funding source, prior to the disclosure of information, in all seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Target Date 1/5/2022
the Clinical Supervisor and the Vice President of Operations will work together to provide counseling to all clinical staff during weekly clinical meeting about the need to complete a release for the payor. By 1/5/2022, Each therapist will be required to complete the release with the service recipients on their respective caseloads and for all new service recipients admitted into the program.
The VP of Operations will audit these files between 1/5 and 1/15 for completion. The VP of Ops. will also review monthly all new admissions to ensure that this release, as well as others have been completed. |
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 client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that 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 and that no client may be deprived of a civil right solely by reason of treatment in all seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Target Date 1/31/2022
During the original licensing process, we need to edit our client rights and responsibilities document. this was completed to add 6 new bullet points (including one to address 71 P.S. 1690.107). During our conversion to Microsoft 365, this document was misplaced. Once identified as an oversight, we found and update the document in our Electronic Health Record. We then made this document the only eligible client rights document in the EHR. We also dated the document with the date it was edited (11/29/2021). This document is now in use and we are working to get all current service recipients to sign off on it. New service recipients are only seeing, reading, and acknowledging this document with their electronic signature.
All of the new rights and responsibilities will be updated by 1/31/2021. The Vice President of Operations will conduct a monthly audit of 25% of the charts to ensure that the correct document was completed and available for review in the client record. These audits will begin in February of 2021. |
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.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that 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 in all seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Target Date 1/31/2022
During the original licensing process, we need to edit our client rights and responsibilities document. this was completed to add 6 new bullet points (including one to address non-discrimination of services regardless of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion). During our conversion to Microsoft 365, this document was misplaced. Once identified as an oversight, we found and update the document in our Electronic Health Record. We then made this document the only eligible client rights document in the EHR. We also dated the document with the date it was edited (11/29/2021). This document is now in use and we are working to get all current service recipients to sign off on it. New service recipients are only seeing, reading, and acknowledging this document with their electronic signature.
All of the new rights and responsibilities will be updated by 1/31/2022. The Vice President of Operations will conduct a monthly audit of 25% of the charts to ensure that the correct document was completed and available for review in the client record. These audits will begin in February of 2022. |
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.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to inspect their own records, that 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 and that reasons for removing sections shall be documented in the record in all seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Target Date 1/31/2022
During the original licensing process, we need to edit our client rights and responsibilities document. this was completed to add 6 new bullet points (notification that clients have a right to inspect their record and are notified if documents have been removed). During our conversion to Microsoft 365, this document was misplaced. Once identified as an oversight, we found and update the document in our Electronic Health Record. We then made this document the only eligible client rights document in the EHR. We also dated the document with the date it was edited (11/29/2021). This document is now in use and we are working to get all current service recipients to sign off on it. New service recipients are only seeing, reading, and acknowledging this document with their electronic signature.
All of the new rights and responsibilities will be updated by 1/31/2022. The Vice President of Operations will conduct a monthly audit of 25% of the charts to ensure that the correct document was completed and available for review in the client record. These audits will begin in February of 2022. |
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.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in all seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Target Date 1/31/2022
During the original licensing process, we need to edit our client rights and responsibilities document. this was completed to add 6 new bullet points (Including the right to appeal a decision limiting access to their records). During our conversion to Microsoft 365, this document was misplaced. Once identified as an oversight, we found and update the document in our Electronic Health Record. We then made this document the only eligible client rights document in the EHR. We also dated the document with the date it was edited (11/29/2021). This document is now in use and we are working to get all current service recipients to sign off on it. New service recipients are only seeing, reading, and acknowledging this document with their electronic signature.
All of the new rights and responsibilities will be updated by 1/31/2022. The Vice President of Operations will conduct a monthly audit of 25% of the charts to ensure that the correct document was completed and available for review in the client record. These audits will begin in February of 2022. |
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.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in all seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Target Date 1/31/2022
During the original licensing process, we need to edit our client rights and responsibilities document. this was completed to add 6 new bullet points (Including the right to request removal of inaccurate, irrelevant, outdated, or incomplete information). During our conversion to Microsoft 365, this document was misplaced. Once identified as an oversight, we found and update the document in our Electronic Health Record. We then made this document the only eligible client rights document in the EHR. We also dated the document with the date it was edited (11/29/2021). This document is now in use and we are working to get all current service recipients to sign off on it. New service recipients are only seeing, reading, and acknowledging this document with their electronic signature.
All of the new rights and responsibilities will be updated by 1/31/2022. The Vice President of Operations will conduct a monthly audit of 25% of the charts to ensure that the correct document was completed and available for review in the client record. These audits will begin in February of 2022.
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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.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in all seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Target Date 1/31/2022
During the original licensing process, we need to edit our client rights and responsibilities document. this was completed to add 6 new bullet points (including one to the right to submit a rebuttal to data or memoranda in their record). During our conversion to Microsoft 365, this document was misplaced. Once identified as an oversight, we found and update the document in our Electronic Health Record. We then made this document the only eligible client rights document in the EHR. We also dated the document with the date it was edited (11/29/2021). This document is now in use and we are working to get all current service recipients to sign off on it. New service recipients are only seeing, reading, and acknowledging this document with their electronic signature.
All of the new rights and responsibilities will be updated by 1/31/2022. The Vice President of Operations will conduct a monthly audit of 25% of the charts to ensure that the correct document was completed and available for review in the client record. These audits will begin in February of 2022. |
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 document the type and/or frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in seven of seven client records reviewed.
Client #1 was admitted on May 17, 2021 and was still active at the time of the inspection. The individual treatment plan, dated May 17, 2021, failed to include both the type of services provided and the frequency of those services.
Client #2 was admitted on October 7, 2021 and was still active at the time of the inspection. The individual treatment plan, dated October 7, 2021, failed to include both the type of services provided and the frequency of those services.
Client #3 was admitted on June 10, 2021 and was still active at the time of the inspection. The individual treatment plan, dated June 10, 2021, failed to include the frequency of the services provided.
Client #4 was admitted on June 4, 2021 and was still active at the time of the inspection. The individual treatment plan, dated June 4, 2021, failed to include the frequency of the services provided.
Client #5 was admitted on September 13, 2021 and was discharged on October 28, 2021. The individual treatment plan, dated September 13, 2021, failed to include the types of services to be provided.
Client #6 was admitted on September 9, 2021 and was discharged on November 29, 2021. The individual treatment plan, dated September 9, 2021, failed to include the types of services to be provided.
Client #7 was admitted on July 21, 2021 and was discharged on September 27, 2021. The individual treatment plan, dated July 22, 2021, failed to include the types of services to be provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Target Date 2/15/2022
The Project Coordinator (General Manager) will work with our Electronic Health Record provider to edit the treatment plan document to include two different boxes --- one for the type of service (individual session, group session, family session, IOP -- Group, IOP --- individual, IOP --- Family) and an other category with explanation. We also will add a frequency box that will allow the therapist to determine the frequency of the identified intervention.
Once this document has been edited, the clinical team will be retrained by the clinical supervisor and general manager on how to complete. the clinical supervisor signs off on all treatment plans and will only accept treatment plans that cover type and frequency of intervention provided. The vice president of operations will review 10% of the clinical records each month to ensure the clinical supervisor is effectively auditing treatment plans prior to approving them.
Our current treatment plan would allow for the above to take place, but the therapist/clinician would need to remember to type in frequency and type in one box. By creating two separate boxes, we address the ongoing concern.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in two of four applicable client records reviewed.
Client # 3 was admitted on June 10, 2021 and was still active at the time of the inspection. The individual treatment plan was completed on June 10, 2021 and the first update was due no later than August 10, 2021; however, the update was not completed until August 31, 2021.
Client # 6 was admitted on September 9, 2021 and was discharged on November 29, 2021. The individual treatment plan was completed on September 9, 2021 and the first update was due no later than November 9, 2021; however, the update was not completed prior to the client ' s discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Target Date 1/31/2022
The VP of Operations will complete a review each week of all treatment plans due for that week. S/he will then audit at the end of the week to ensure all treatment plans were completed by the assigned counselor by the date required.
The VP of Operations will present audit findings during clinical case review meeting every Monday for the previous week as well a list of treatment plans due for the following 14 days. These lists will be reviewed weekly moving forward. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include aftercare plans, in one of one applicable client record reviewed.
Client # 5 was admitted on September 13, 2021 and was successfully discharged on November 8, 2021. There was no documentation of an aftercare plan in the record 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
Target Date: 12/9/2021
This was a training oversight. The therapist was not aware of the aftercare document that was available in the electronic health record. All staff have now received guidance on how to access and complete the aftercare plan. The General Manager of the Practice will review each discharge for completion before the individual record is closed to ensure completion of all necessary documents, including the aftercare plan document. |
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, which is to include follow-up information, in four of four applicable client records reviewed.
Client #4 was admitted on June 4, 2021 and was still active at the time of the inspection. There was no documentation of follow-up information in the record as of the date of the inspection.
Client #5 was admitted on September 13, 2021 and was discharged on October 28, 2021. There was no documentation of follow-up information in the record as of the date of the inspection.
Client #6 was admitted on September 9, 2021 and was discharged on November 29, 2021. There was no documentation of follow-up information in the record as of the date of the inspection.
Client #7 was admitted on July 21, 2021 and was discharged on September 27, 2021. There was no documentation of follow-up information in the record 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
Target Date 1/31/2022
The VP of Operations will reach out to all service recipients discharged within 30 days of the date of discharge. S/he will document the telephonic visit in the case management section of the electronic health record. The document will be named post-discharge follow up. The Vice President of Operations will maintain a list of all discharged clients and will check off once the post discharge follow up call was completed. |