INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on July 6, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Chartiers Community Mental Health and Retardation Center, Inc. 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) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on an onsite inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
On July 6, 2023, fire extinguishers in the facility were last inspected in February 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Fire extinguishers were serviced and refilled immediately on July 7, 2023. The Facilities Manager has developed a routine schedule with Fire Management Company in which they will inspect and service the fire extinguishers on a routine basis. Next scheduled service inspection is October 2023. |
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 document a written, informed and voluntary consent from the client prior to the disclosure of information in two of five applicable client records.
The facility billed for treatment services without written consent from the client in the following records:
Client # 2 was admitted March 29, 2023 and was discharged on June 23, 2023.
Client # 5 was admitted March 22, 2023 and is currently active.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat deficiency from the February 7, 2022 and the January 9 & 13, 2023 annual licensing inspection.
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Plan of Correction
Client #2 has a consent for the insurance company dated 4/19/2023 but is unsigned by the client. Therapist has been instructed on proper procedure for obtaining consent at intake on 7/19/2023 and a review and second signature by the Clinical Administrator is currently required to ensure that consents are obtained and completed thoroughly. Client #2 is no longer in treatment and an updated consent cannot be obtained. Client #5 has been hospitalized; if/when he returns to treatment this agency will obtain an updated consent.
The Clinical Administrator will review all new cases upon admission to ensure all necessary consents are obtained. A spreadsheet will be maintained by the Clinical Administrator and Admin Support to track expiring consents and ensure that therapists obtain necessary consents on an annual/as needed basis. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system that allowed for the identification of clients' admission and discharge dates within a specific time period.
The facility provided a written list of clients. The dates documented on the written list did not correspond with the dates in the electronic medical record system. Six of twelve client records that were attempted to be reviewed had discrepancies between the written list provided and the electronic medical record system.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The report used during the licensing visit pulls the initial date of contact as the "Admission Date." However, we consider the date of the Needs Assessment to be the "Admission Date." We will work with our IT team to create a report that will correctly generate the Needs Assessment date as the Admission Date. This will be created by 9/1/2023 and will be available for use for all upcoming licensing visits.
With this, DDAP auditors will be provided with accurate lists to include admission and discharge dates. The Clinical Administrator will be responsible to ensure that the list is created and maintained. |
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 of treatment services on the treatment plan in six of six client records.
Client # 1 was admitted March 13, 2023 and is currently active. A Treatment plan dated March 20, 2023 did not include documentation of the type of treatment services.
Client # 2 was admitted March 29, 2023 and was discharged on June 23, 2023. A Treatment plan dated April 19, 2023 did not include documentation of the type of treatment services.
Client # 3 was admitted April 24, 2023 and was discharged on May 24, 2023. A Treatment plan dated May 11, 2023 did not include documentation of the type of treatment services.
Client # 4 was admitted March 23, 2023 and was discharged on May 24, 2023. A Treatment plan dated March 23, 2023 did not include documentation of the type of treatment services.
Client # 5 was admitted March 22, 2023 and is currently active. A Treatment plan dated April 3, 2023 and May 17, 2023 did not include documentation of the type of treatment services.
Client # 6 was admitted May 12, 2023 and is currently active. A Treatment plan dated May 31, 2023 did not include documentation of the type of treatment services.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat deficiency from the January 9 & 13, 2023 annual licensing inspection.
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Plan of Correction
Staff have been trained to include the Type/Frequency, scheduled days to attend treatment and level of treatment (OP/IOP) on all Treatment Plans. The Clinical Administrator of Recovery Treatment Services shall review and approve all Treatment Plans and ensure the required documentation is present. |
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 document follow up contact, within one week as per facility policy, in one of three applicable client records.
Client # 2 was admitted March 29, 2023 and was discharged on June 23, 2023. There was no follow up contact documented in client record #2.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat deficiency from the January 9 & 13, 2023 annual licensing inspection.
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Plan of Correction
The Clinical Administrator of Recovery Treatment Services met with Therapist on 7/19/2023 and developed a supervision plan regarding all documentation and DDAP standards regarding expectations. Follow-Ups reminded to be completed within 7-days of discharge and made part of the supervision plan. The Clinical Administrator of Recovery Treatment Services will be responsible to track the completion of follow ups and ensure completion in the time frame required. |
709.15(b) LICENSURE Subchapter B.Licensing Procedures.Right to en
709.15. Right to enter and inspect.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
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Observations
Based on a review of client records, the facility failed to provide full and free access to the client records.
The facility did not grant the electronic permissions needed for full access to all current and discharged clients identified for the inspection review period. The facility required auditors to preselect clients that they then uploaded prior to auditors having access to the entire record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
We have amended our current process and created an auditor case list that meets confidentiality requirements yet permits auditor access to all identified clients.
the clinical administrator of recovery Treatment Services will be responsible to monitor the auditor caselist to ensure access to all D/A clients.
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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 approved by the Department.
A plan of correction for a consent to release information to the funding source was submitted and approved by the Department for the January 9 & 13, 2023, and February 7, 2022, annual licensing inspections. Consent to release information to the funding source was again found to be a deficiency in the July 6, 2023, licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Administrator of Recovery Treatment Services completes weekly supervisions with each therapist to review and address documentation issues. In addition, an Opening Checklist Packet is being developed to assist in ensuring completion of all required documentation and will be implemented by 7/31/2023. The Clinical Administrator of Recovery Treatment Services will be responsible to track and ensure completion of all required documents.
Any future Plans of Correction will be reviewed with staff immediately, once approved by DDAP. Staff will then be trained in how the program will measure deficiencies, how deficiencies will be tracked, how the program will ensure compliance, tracking tools, and the new criteria for monitoring. All staff will then sign off on the training and understand these implementations. The Clinical Administrator of Recovery Treatment Services will be responsible to provide training, monitor progress and track compliance.
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