INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 20, 2020 through February 21, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Providence Treatment 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to adhere to the project's policy and procedure on collecting feedback on completed trainings. Every employee-completed training documented failed to have a completed feedback form in each employee record reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff development program is not applicable as all staff are contracted staff. The project policy and procedure has since revised after the DDAP inspection on 2/20/20. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to demonstrate sufficient coverage of staff certified in CPR or First Aid during the facility's hours of operation, which was identified as being 9AM to 9PM Monday through Friday. The facility demonstrated CPR and First Aid coverage for only 16 hours per week.
The findings were reviewed with facility staff during the licensing process
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Plan of Correction
Leadership staff obtained their CPR/First Aid training certificates by 3/18/20.
All other staff will obtain their CPR certs by 4/15/20, or when the training becomes available due to suspension of CPR trainings due to the COVID-19 health crisis.
The Chief Operation Officer will amend all contracts for all contracted clinical staff going forward to include the requirement of keeping CPR/First Aid current. Facility Director will perform monthly audits on each staff person's HR records to ensure active certification for CPR/First Aid compliance. |
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
The facility failed to document whether the fire alarm or smoke detector was operative during each fire drill for the reviewed time period of April 2019 to January 2020. Additionally, the facility failed to utilize alternate exit routes during fire drills conducted from April 2019 to January 2020. The facility only used the "closest exit to the glass office door" during these drills.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective March 1, 2020, the facility will test the functionality of smoke detector to imitate the sound of fire alarm during their fire drill. The facility is equipped with central fire sprinkler and fire alarm system.
Effective March 1, 2020, the facility will utilize both egress exits alternately located on the main floor during their monthly fire drill.
The Facility Director will perform monthly audits to ensure the smoke detector is utilized and alternate exit routes are used for all fire drills. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
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Plan of Correction
The Chief Operations Officer (COO) will obtain the annual financial audit from an independent certified public accountant for fiscal year 2020 and onward accordingly to DDAP's requirement.
The COO will also ensure the annual audit for fiscal year 2019 is completed by 8/15/20. COO will also ensure future annual audit is completed accordingly by 2/15 going forward. |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in 13 of 14 client records reviewed.
Client # 1 was admitted to the partial hospitalization level of care on February 7, 2020 and was still active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file. Additionally, there was documentation that bodily fluid samples were sent to two laboratories numerous times; however, there were no consent to release information forms on file prior to the disclosures.
Client # 3 was admitted to the partial hospitalization level of care on February 17, 2020 and was still active at the time of the inspection. There was documentation that bodily fluid samples were sent to two laboratories numerous times; however, there were no consent to release information forms on file prior to the disclosures.
Client # 4 was admitted to the partial hospitalization level of care on October 21, 2019 and was discharged on October 28, 2019. There was documentation that bodily fluid samples were sent to two laboratories numerous times; however, there were no consent to release information forms on file prior to the disclosures.
Client # 5 was admitted to the partial hospitalization level of care on May 21, 2019 and was discharged on June 10, 2019. There was documentation that bodily fluid samples were sent to two laboratories numerous times; however, there were no consent to release information forms on file prior to the disclosures.
Client # 6 was admitted to the partial hospitalization level of care on August 23, 2019 and was discharged on September 4, 2019. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file. Additionally, there was documentation that bodily fluid samples were sent to two laboratories numerous times; however, there were no consent to release information forms on file prior to the disclosures.
Client # 7 was admitted to the partial hospitalization level of care on December 16, 2019 and was discharged on January 8, 2020. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file. Additionally, there was documentation that bodily fluid samples were sent to two laboratories numerous times; however, there were no consent to release information forms on file prior to the disclosures.
Client # 8 was admitted to the outpatient level of care on October 28, 2019 and was still active at the time of the inspection. There was documentation that bodily fluid samples were sent to two laboratories numerous times; however, there were no consent to release information forms on file prior to the disclosures.
Client # 9 was admitted to the outpatient level of care on June 10, 2019 and was still active at the time of the inspection. There was documentation that bodily fluid samples were sent to two laboratories numerous times; however, there were no consent to release information forms on file prior to the disclosures.
Client # 10 was admitted to the outpatient level of care on September 4, 2019 and was still active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file. Additionally, there was documentation that bodily fluid samples were sent to two laboratories numerous times; however, there were no consent to release information forms on file prior to the disclosures.
Client # 11 was admitted to the outpatient level of care on September 20, 2019 and was discharged on January 2, 2020. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file. Additionally, there was documentation that bodily fluid samples were sent to two laboratories numerous times; however, there were no consent to release information forms on file prior to the disclosures.
Client # 12 was admitted to the outpatient level of care on April 29, 2019 and was discharged on August 14, 2019. There was documentation of the facility billing the funding source; however, there was no consent to release information form to the funding source on file. Additionally, there was documentation that bodily fluid samples were sent to two laboratories numerous times; however, there were no consent to release information forms on file prior to the disclosures.
Client # 13 was admitted to the outpatient level of care on July 12, 2019 and was discharged on January 3, 2020. There was documentation that bodily fluid samples were sent to two laboratories numerous times; however, there were no consent to release information forms on file prior to the disclosures.
Client # 14 was admitted to the outpatient level of care on May 13, 2019 and was discharged on September 9, 2019. There was documentation that bodily fluid samples were sent to two laboratories numerous times; however, there were no consent to release information forms on file prior to the disclosures.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Chief Operation Officer (COO) has obtained QSOA with the testing agency on 3/12/2020 between the Covered Entity and Business Associate to comply with 42 CFR Part 2 regarding the use and disclosure of client information in a substance abuse treatment facility. This QSOA agreement addressed the deficiencies for Client #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14. All future testing reporting is covered under this QSOA.
Client #1, #6 are self pay. Consent to release information to the funding source is not applicable.
Client #10 signed consent to release information to funding source on 2/13/20.
Client #7 & #11 signed consent to release information to funding source on 3/19/20.
Client #12 signed the consent to release information to funding source on 5/15/19.
COO will update the intake admission policy and procedure to ensure consent to release information for the funding source is signed by all new clients at the time of admission. Admission staff was trained on 2/28/20 regarding this expectation.
COO will perform audits to ensure compliance for the consent to release information to the funding source is completed for all active clients by 4/15/20.
COO will perform monthly audits to ensure compliance for the consent to release information to the funding source is completed for all future clients. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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 client records, the facility failed to document that an individual treatment and rehabilitation plan was developed with the client in three of five applicable client records reviewed.
Client # 1 was admitted on February 7, 2020 and was active at the time of the inspection. The client record did not include an individual treatment and rehabilitation plan.
Client # 5 was admitted on May 21, 2019 and was discharged on June 10, 2019. The record did not contain an individual treatment and rehabilitation plan in the partial hospitalization level of care.
Client # 7 was admitted on August 12, 2019 and was discharged on January 3, 2020. The individual treatment and rehabilitation plan was dated December 16, 2019. The treatment plan did not contain the client signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that all clients will have their master treatment plan developed within 14 business days after initial admission and obtain the client's signature.
The Facility Director has provided staff training on 2/28/20 to all clinical staff regarding this expectation.
The Facility Director will perform monthly chart audit to ensure compliance of this expectation.
The project policy and procedure was revised on 2/20/20 to change the duration of 7 business days to 14 business days for the master treatment plan development. |
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.
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Observations
The facility failed to provide counseling to a client on a regular and scheduled basis, which is to include individual counseling at least twice a week, in four of seven client records reviewed in the partial hospitalization activity.
Client # 1 was admitted on February 7, 2020 and was active at the time of the inspection. Documentation of two individual sessions per week was not completed for the week of February 10, 2019 to February 14, 2019.
Client # 5 was admitted on May 21, 2019 and was discharged on June 10, 2019. Documentation of two individual sessions per week was not completed for the weeks of May 27, 2019 to May 31, 2019 and June 3, 2019 to June 7, 2019.
Client # 6 was admitted on August 23, 2019 and was discharged on September 4, 2019. Documentation of two individual sessions per week was not completed for the week of August 26, 2019 to August 30, 2019.
Client # 7 was admitted on December 16, 2019 and was discharged on January 8, 2020. Documentation of two individual sessions per week was not completed for the week of December 23, 2019 to December 27, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 3/16/2020, the facility will include 2 individual counseling sessions per week for their clients who are in the partial hospitalization activity.
The Facility Director will present the weekly schedule to their clients who are in partial hospitalization activity.
The Facility Director will perform monthly chart audit to ensure compliance of this expectation. |
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
The facility failed to provide a complete client record, which is to include case consultation notes and follow-up information, in five of seven client records.
Client # 9 was admitted on June 10, 2019 and was active at the time of the inspection. The record was missing documentation of the completion of a case consultation notes.
Client # 10 was admitted on September 4, 2019 and was active at the time of the inspection. The record was missing documentation of the completion of a case consultation notes.
Client # 12 was admitted on August 12, 2019 and was discharged on January 3, 2020. The record was missing documentation of the completion of follow up information.
Client # 13 was admitted on July 12, 2019 and was discharged on January 3, 2020. The record was missing documentation of the completion of a case consultation notes.
Client # 14 was admitted on May 13, 2019 and was discharged on September 9, 2019. The record was missing documentation of the completion of a case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has provided staff training on 2/28/2020 to all clinical staff regarding case consultation for their active clients who continue to receive treatment more than 90 days.
The Facility Director has provided staff training on 2/28/2020 to all staff regarding 7-day follow up with clients who have been discharged from the facility. The project policy and procedure was revised on 2/20/20 to reflect the change of 7-day follow up requirement.
The Facility Director will perform monthly chart audit to ensure compliance of case consultation and follow up expectations.
The Facility Director will complete the case consultation for client #9, #10, #13, and #14 by 4/15/20.
The Chief Operation Office will complete the follow up with client #12 by 3/25/20. |