INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 17, 2024 through October 18, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Huntingdon Valley Comprehensive Treatment Center 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of nine personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.
Employee # 8 was hired as a counselor on September 3, 2024 and was current in that position at the time of the inspection. At the time of hire, the employee did not have a qualifying degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director filed an exception with the state on 10/21/24. Clinic Director and Clinical Supervisor will treat Counselor as a counselor assistant adherent to all of the §704.8 & 704.9 regulations from the date of this draft and pending the response to the aforementioned exception filed on behalf of this employee, is received
Received a request for more information and will send in by end of day 11/15/24.
Director will better screen applicants for appropriate degrees and if hiring based on experience, will file the exception needed.
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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 obtain an informed and voluntary consent from the client for the disclosure of information in five of nine records reviewed.
Client # 1 was admitted on August 21, 2013 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source, which was signed by the client on October 9, 2013 and was in effect from October 9, 2013 through October 9, 2024, did not allow for the release of that information.
Client # 2 was admitted on May 31, 2022 and was discharged on September 10, 2024. The record contained documentation that urinalysis results, dosing history, program attendance, and progress were sent to a government agency on February 28, 2024; however, the consent to release information form to the agency signed by the client on February 22, 2024, did not allow for the release of that information.
Client # 3 was admitted on September 16, 2024 and was active at the time of the inspection. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
Client # 5 was admitted on January 4, 2024 and was active at the time of the inspection. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
Client # 6 was admitted on March 11, 2024 and was active at the time of the inspection. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
This is a repeat citation from the October 13, 2023, January 13, 2022, and November 17, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
During the All Staff Monthly Team Meeting on 11/12/24, the Clinic Director and Clinical Supervisor will provide a review of the Release of Information consent process with all staff. The Regional Director will be scheduled to conduct a training for all staff engaged in obtaining such; training will occur prior to end of year.
All aspects of a patients release and appropriate data that may be released based on receiving party will be presented....
All charts cited will be updated by 11/15/24. Training of all staff to occur by 11/12/24 with follow up training by Regional Director by end of year.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of nine client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.
Client # 2 was admitted on May 31, 2022 and was involuntarily discharged on September 10, 2024. The record contained no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A review and training of the discharge process will be provided by the Clinic Director and Clinical supervisor to all counseling staff during group supervision on 11/12/24. The Clinic Director and Clinical Supervisor will review and document compliance to written notification having been provided to patient following the facilities decision to involuntarily terminate Pt's. treatment.
As most determinations are reviewed and decisions made during MDT, MDT notations will also be made therein to ensure compliance to §709.33(a).
Clinical Supervisor will continue reviews of staff compliance during weekly individual and group supervision sessions.
Training for all staff to occur by 11/12/24
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of 21 weeks of physician and physician assistant timesheets, the facility failed to provide at least one hour of physician time a week on site for every ten patients in one week reviewed.
During the week of May 19, 2024 through May 25, 2024, the patient census was 353. The facility was required to provide at least 35.3 physician hours. There were only 31 hours documented.
During the week of June 30, 2024 through July 6, 2024, the patient census was 354. The facility was required to provide at least 35.4 physician hours. There were only 32.25 hours documented.
During the week of September 1, 2024 through September 7, 2024, the patient census was 354. The facility was required to provide at least 35.4 physician hours. There were only 14 hours documented.
This is a repeat citation from the October 13, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Clinic Director to meet with Medical Director to review process for medical coverage in case of absence by either a doctor or Physician assistant. This meeting to occur by 11/13/24.
Clinic Director to ensure that there is medical coverage during all vacations of PA and/or doctor and during any illness that may affect medical coverage
Clinic Director and nursing staff to work with medical staff to ensure all proper coverage and document such in a newly formed binder that tracks all physician staffing that is in Director's office. Binder to be completed by 11/15/24
Clinic Director will file for an exception to coverage if there is not suitable coverage during vacations of medical staff.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to ensure that verification of the individual ' s identity and emergency contact information were obtained during the intake process in three applicable records reviewed.
Patient # 3 was admitted on September 16, 2024 and was active at the time of the inspection. Emergency contact information was not obtained until October 8, 2024, and the record contained no documentation showing that the patient declined to provide it during the intake process or that there was a lapse in attendance preventing the information from being gathered.
Patient # 5 was admitted on January 4, 2024 and was active at the time of the inspection. Documentation that the individual ' s identity was verified, and emergency contact information were not obtained during intake, and the record contained no documentation showing that the patient declined to provide it during the intake process or that there was a lapse in attendance preventing the information from being gathered.
Patient # 9 was admitted on December 7, 2013 and was discharged on September 13, 2024. Documentation that the individual ' s identity was verified was not obtained until January 12, 2024, and the record contained no documentation showing that the patient declined to provide it during the intake process or that there was a lapse in attendance preventing the information from being gathered.
This is a repeat citation from the October 13, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Clinic Director and Clinical Supervisor will review consent process with all staff, including but not limited to anyone who does intakes.
Will review that a consent for emergency contact must be singed at time of intake. If patients refuse, it must be documented in the consent and in the chart. Clinicians will be encouraged to have the patient identify an emergency contact. If a patient revokes consent, it must be documented.
Director and supervisor will work together with front desk staff on obtaining identification from patient at time of intake. If patient does not have a form of identification, they will meet with case management team to help obtain identification. In the meantime, patients must have something to prove who they are prior to being admitted. CS will review all intake charts monthly via the quality record review process.
All charts cited will be updated by 11/15/24 Training of all staff to occur by 11/12/24.
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715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on a review of patient records, the narcotic treatment physician failed to document in the patient record the rationale for permitting take-home medication in six applicable records reviewed.
Patient # 1 was admitted on August 21, 2013 and was active at the time of the inspection. The patient received take-home medications weekly beginning on August 2, 2024, and the rationale for take-home medication was not documented by the physician as of the date of the inspection.
Patient # 2 was admitted on May 31, 2022 and was discharged on September 10, 2024. The patient received take-home medications weekly beginning on July 12, 2024, and the rationale for take-home medication was not documented by the physician as of the date of the inspection.
Patient # 3 was admitted on September 16, 2024 and was active at the time of the inspection. The patient received take-home medications weekly beginning on September 20, 2024, and the rationale for take-home medication was not documented by the physician as of the date of the inspection.
Patient # 5 was admitted on January 4, 2024 and was active at the time of the inspection. The patient received take-home medications weekly beginning on July 13, 2024, and the rationale for take-home medication was not documented by the physician as of the date of the inspection. Take-home medications were received on August 30, 2024, and the rationale for take-home medication was not documented by the physician as of the date of the inspection.
Patient # 6 was admitted on March 11, 2024 and was active at the time of the inspection. The patient received take-home medications on June 27, 2024, and the rationale for take-home medication was not documented by the physician as of the date of the inspection.
Patient # 8 was admitted on July 16, 2003 and was active at the time of the inspection. The patient received take-home medications biweekly beginning on June 4, 2024, and the rationale for take-home medication was not documented by the physician 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
Clinic Director to work with Medical Director to make sure that all take home orders have been properly documented. Clinic director and medical director to work together to ensure that all patients have a justification in the chart for their weekend take homes as the clinic is now closed on weekends. CS will also monitor monthly via the Quality Record Review Process.
All cited charts will be corrected by 11/25/24 with all charts being updated by end of calendar year, 12/31/24.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on an observation of medication administration on October 18, 2024, the nurse in the second medication window was observed to be preparing take-home medications or looking at a computer monitor, instead of observing the patient when ingesting the agent at 09:22 a.m. and 09:44 a.m.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director and Charge Nurse will work with all dispensing nurses to ensure that they carefully monitor and observe all patients while taking their medication, including the dissolvable medications that may take a few extra minutes to dissolve.
All nurses to be re-trained and re-educated by 11/12/24. Director did speak to charge nurse following the site inspection regarding this issue on 10/21/24.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to ensure an annual physical reevaluation in three of five applicable records reviewed.
Patient # 1 was admitted on August 21, 2013 and was active at the time of the inspection. The most recent annual physical was completed on July 17, 2023.
Patient # 2 was admitted on May 31, 2022 and was discharged on September 10, 2024. The most recent annual physical evaluation was completed on July 25, 2023.
Patient # 8 was admitted on July 16, 2003 and was active at the time of the inspection. The most recent annual physical evaluation was completed on August 3, 2023.
This is a repeat citation from the October 13, 2023, January 13, 2022 and November 17, 2022 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
A mandatory training for medical staff will
be provided by the Director by 11/20/24 which will review
that all Annual Medical
Assessments/Physical Assessment are to be scheduled a minimum of two weeks prior to the
scheduled due date in the EMR to ensure that completion of the
required documentation is timely.
Medical Director, Clinic Director and Charge Nurse to work together to improve scheduling of physicals for PA to complete. PA has also been asked to complete a minimum of 10-15 physicals a week.
The Clinic Director will review the services due report in the EMR a
minimum of once per week with CTC
leadership to ensure patients are scheduled for and complete their
annual physicals timely. Charge nurse will monitor, monthly, via the Quality record review process, for the
completion of annual physical examinations, along with Medical
Director.
Medical Director, Clinic Director and Charge nurse will monitor PA to make sure that physicals are being completed. All cited charts will be completed by 12/27/24
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document a completed annual evaluation signed by the medical director in four of five applicable records.
Patient # 1 was admitted on August 21, 2013 and was active at the time of the inspection. The annual evaluation was due to be completed by August 21, 2024; however, the annual evaluation was not completed until October 11, 2024.
Patient # 4 was admitted on May 22, 2017 and was discharged on August 12, 2024. The annual evaluation completed on May 8, 2024 was not signed by the medical director.
Patient # 7 was admitted on May 6, 2019 and was discharged on May 14, 2024. The annual evaluation was due to be completed by May 6, 2024; however, the annual evaluation was not completed as of the date of the inspection.
Patient # 8 was admitted on July 16, 2003 and was active at the time of the inspection. The annual evaluation was due to be completed by July 16, 2024; however, the annual evaluation was not completed as of the date of the inspection.
This is a repeat citation from the October 13, 2023, January 13, 2022 and November 17, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory training for all staff will be provided by the Director by
11/12/24 which will review ALL documentation requirements and timelines including that all Annual Clinical
Evaluations are to be scheduled a minimum of two weeks prior to the
scheduled due date in the EMR to ensure that completion of the
required documentation is timely.
The Clinic Director and Clinical Supervisor will review the services due report in the EMR a minimum of once per week to ensure annual clinical evaluations are completed timely. CS will also monitor monthly via the Quality Record Review Process.
Charge nurse will monitor, weekly,
along with Medical Director to ensure that annual evaluations are
completed.
Clinic director will also review the signature pending area in the EMR to ensure things are being signed off on in a timely manner.
All missing evaluations to be completed by end of year. All cited charts to be completed by 11/27/24
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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 client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation in three of four applicable records reviewed. The facility policy states that new admissions are to have a psychosocial evaluation completed within 30 days of admission, and readmissions are to have a psychosocial addendum completed within 7 days of admission.
Client # 3 was admitted on September 16, 2024 and was active at the time of the inspection. The record did not contain a psychosocial addendum as of the date of the inspection.
Client # 5 was admitted on January 4, 2024 and was active at the time of the inspection. The psychosocial evaluation was not completed until March 1, 2024.
Client # 9 was admitted on December 7, 2023 and was discharged on September 13, 2024. The psychosocial evaluation was not completed until March 29, 2024.
This is a repeat citation from the October 13, 2023 annual licensing renewal inspection.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
A mandatory training for all staff will be provided by the Director and Clinical Supervisor by
11/14/24 which will review ALL documentation
requirements and timelines.
Director will also meet with Supervisor on working to get patients assigned to a counselor in a more timely manner or working to get the assessments completed timely if no counselor is available.
All cited charts to be up to date by 11/27/24
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a preliminary treatment plan within seven days of admission, per policy, in two of four applicable records reviewed.
Client # 3 was admitted on September 16, 2024 and was active at the time of the inspection. The record did not contain a preliminary treatment plan.
Client # 5 was admitted on January 4, 2024 and was active at the time of the inspection. The record did not contain a preliminary treatment plan.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will work with Clinical Supervisor and all staff who complete intakes to insure that all patients have a preliminary treatment plan prior to leaving intake. This training to occur by 11/12/24 and all cited charts to be up to date by 11/27/24. CS will review all intake charts monthly via the quality record review process to ensure compliance.
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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 client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within 30 days of admission, per the facility policy, in two of four applicable records reviewed.
Client # 3 was admitted on September 16, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by October 16, 2024; however, it was not completed as of the date of the inspection.
Client # 5 was admitted on January 4, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by February 4, 2024; however, it was not completed until February 16, 2024.
This is a repeat citation from the October 13, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory training for all staff will be provided by the Director and Clinical Supervisor by
11/12/24 which will review ALL documentation requirements and timelines.
Director will also meet with Supervisor on working to get patients assigned to a counselor in a more timely manner or working to get the treatment plans completed timely if no counselor is available. Will also utilize Lead Counselor if needed. CS will monitor monthly via the Quality Record Review Process.
All cited charts to be corrected by 11/27/24
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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 document treatment plan updates within the regulatory timeframe in seven of eight applicable records reviewed.
Client # 1 was admitted on August 21, 2013 and was active at the time of the inspection. A treatment plan update was completed on December 18, 2023, and the next update was due no later than February 15, 2024; however, the next treatment plan update was not completed until February 19, 2024. A treatment plan update was completed on June 18, 2024 and the next treatment plan update was due to be completed by August 16, 2024; however, the treatment plan update was not completed until August 30, 2024.
Client # 2 was admitted on May 31, 2022 and was discharged on September 10, 2024. A treatment plan update was completed on March 25, 2024, and the next update was due no later than May 23, 2024; however, the next treatment plan update was not completed until May 29, 2024.
Client # 4 was admitted on May 22, 2017 and was discharged on August 12, 2024. A treatment plan update was completed on January 2, 2024, and the next update was due no later than March 1, 2024; however, the next treatment plan update was not completed until March 14, 2024.
Client # 5 was admitted on January 4, 2024 and was active at the time of the inspection. A treatment plan update was completed on May 1, 2024, and the next update was due no later than June 29, 2024; however, the next treatment plan update was not completed until July 3, 2024. The next treatment plan update was due to be completed by August 31, 2024; however, the next update was not completed until September 6, 2024.
Client # 6 was admitted on March 11, 2024 and was active at the time of the inspection. A treatment plan update was completed on July 9, 2024, and the next update was due no later than September 6, 2024; however, the next treatment plan update was not completed until September 12, 2024.
Client # 8 was admitted on July 16, 2003 and was active at the time of the inspection. A treatment plan update was completed on March 29, 2024, and the next update was due no later than May 27, 2024; however, the next treatment plan update was not completed until May 30, 2024. A treatment plan update was completed on July 23, 2024, and the next update was due no later than September 20, 2024; however, the next treatment plan update was not completed until September 26, 2024.
Client # 9 was admitted on December 7, 2023 and was discharged on September 13, 2024. A treatment plan update was completed on June 3, 2024, and the next update was due no later than August 1, 2024; however, the next treatment plan update was not completed until August 7, 2024.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
A mandatory training for all staff will be provided
by the Director and Clinical Supervisor by
11/12/24 which will review ALL documentation requirements and timelines.
Supervisor will work with counselors to help them budget their time, stay on top of deadlines, etc. Will also utilize Lead Counselor if needed
All cited charts to be corrected by 11/27/24
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in three of eight applicable records reviewed.
Client # 1 was admitted on August 21, 2013 and was active at the time of the inspection. Treatment plans completed on February 19, 2024 and April 18, 2024, indicated that the client was to receive one hour of individual counseling per month; however, the record did not contain documentation of any individual sessions during the month of March 2024 and only 30 minutes of counseling during April 2024.
Client # 4 was admitted on May 22, 2017 and was discharged on August 12, 2024. Treatment plans completed on November 27, 2023, January 2, 2024, and March 14, 2024, indicated that the client was to receive one hour of counseling per month; however, the record did not contain documentation of any counseling sessions during January, February, or April 2024.
Client # 6 was admitted on March 11, 2024 and was active at the time of the inspection. Treatment plans completed on May 9, 2024, July 9, 2024, and September 12, 2024, indicated that the client was to receive two hours of individual counseling per month and three hours of group counseling per month; however, the record did not contain documentation of any counseling sessions during June, July, August, or September 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director and Clinical Supervisor will review with clinical staff the engagement practices of the clinic. Staff will be re-trained and re-educated on engagement of all patients and ensuring that patients meet their needed hours as prescribed in the treatment plan.
Staff does complete General notes at the end of the month to document why patients did not meet hours. Clinical Supervisor will monitor monthly via the Quality Record Review Process to ensure compliance.
Staff to also be re-trained and re-educated on documenting if a session is cancelled by patient, clinician or if patient is a no show.
Training to occur by 11/27/24
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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 ensure a complete client record included information relative to the client's involvement with the project to include follow-up information at 30 days post discharge, per facility policy, in two of three applicable records reviewed.
Client # 7 was admitted on May 6, 2019 and was discharged on May 14, 2024. The client record did not contain documentation of follow-up information.
Client # 9 was admitted on December 7, 2013 and was discharged on September 13, 2024. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor to hold documentation training with all clinical staff by 11/27/24 to address all discharge paperwork that needs to be completed and the timeline that it needs to occur in.
Supervisor will check in the EMR weekly to see what discharges have happened and check charts to ensure that all discharge paperwork is being taken care of.
All cited charts to be corrected by 11/27/24
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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 obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the October 13, 2023, November 17, 2022, and January 13, 2022, annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the October 17, 2024 through October 18, 2024 licensing inspection.
A plan of correction for completing patient physicals annually was submitted and approved by the Department for the October 13, 2023, November 17, 2022, and January 13, 2022, annual licensing inspections. Annual physicals were again found to be a deficiency in the October 17, 2024 through October 18, 2024 licensing inspection.
A plan of correction for completing annual evaluations was submitted and approved by the Department for the October 13, 2023, November 17, 2022, and January 13, 2022, annual licensing inspections. Annual evaluations were again found to be a deficiency in the October 17, 2024 through October 18, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director and Clinical supervisor to educate and train new staff on all policies and timelines as noted.
Director to follow up on POC in a more diligent manner and work with staff to ensure that all corrections are made. Changes/follow-up to be tracked via meeting minutes, documentation reviews, supervision with Clinical Supervisor.
Director to give copy of POC to management team so that all members of team can continue to work on issues as needed.
Trainings will be held for all POC's following their submissions and approvals. New staff and existing staff need to be trained regularly to ensure that these issues do not continue to come up
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