INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, PHMC Pathways to Recovery was found to be not 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) (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
Based on a review of the fire drill record, conducted on July 26, 2018, the facility failed to document on the fire drill record any problems encountered and whether the fire alarm or smoke detector or fire alarm was operative from August 2017 thru July 2018.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Fire drill record form was updated on 9/4/18 to include: date, day of the week, time of drill, amount of time it took for evacuation, number of people evacuated, location of fire, meeting place, exit route used, problems encountered and whether the fire alarm and smoke detector were operational.
Staff will be trained on 9/17/18 on the updated form and information to be captured during each drill. Will be monitored monthly by program director to ensure written fire drill record is thorough and complete.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Seven partial hospitalization client records were reviewed on July 26, 2018. The facility failed to document a valid consent to release information form in records, #1 and 7.
Client #1 was admitted on 6/1/18 and was an active client at the time of the licensing inspection. A consent to release information to a provider, dated 7/23/18, did not specify the information to be released or the purpose of the information to be released.
Client #7 was admitted on 2/28/18 and was discharged on 3/29/18.
A consent to release information to a government agency, dated 4/17/18, did not specify the information to be released. Additionally, a consent to release information to a case manager, dated 4/17/18, did not specify the purpose of the information to be released.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Confidentiality Policy and Procedure for PHMC-Pathways to Recovery will be updated by October 1, 2018 and a training is scheduled for October 24, 2018. The training will cover confidentiality of client identity and records and will include plans to address security and the release of electronic and paper records.
A new consent to release information for Client #1 was completed on 7/27/18. The consent now specifies the information to be released and the purpose of the information to be released.
The Program Director is responsible for the maintenance of client records. Chart reviews will be completed biweekly by the Clinical Director to ensure compliance. Program Director will conduct chart audits quarterly to confirm ongoing compliance.
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709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Seven partial hospitalization client records were reviewed on July 26, 2018; the facility failed to document a complete drug and alcohol history for clients 2-5 & 7.
Client #2 was admitted on 6/15/18 and was an active client at the time of the licensing inspection.
Client #3 was admitted on 6/4/18 and was an active client at the time of the licensing inspection.
Client #4 was admitted on 9/1/17 and was discharged on 12/8/17.
Client #5 was admitted on 2/8/18 and was discharged on 4/12/18.
Client #7 was admitted on 2/28/18 and was discharged on 5/15/18.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
While the technical support department is working on glitches in this area of the electronic database, Pathways to Recovery will begin completing documentation of these histories on paper by October 15, 2018. A history documenting substances used, most frequently abused, the length and patterns of use and prior treatment episodes. Also included is the participant's perception of their effect on his/her social, physical and mental state and the substance abuse history within the participant's family or significant others.
Thorough drug and alcohol histories were added to active client records to reflect substances most frequently abused, the length and patterns of use, prior treatment episodes as well as their perception of their effect on his/her social, physical and mental state and the substance abuse history within their family/significant others.
Program Director and Clinical Director will train staff on October 10, 2018. Clinical Director will monitor bi-weekly to ensure compliance and thoroughness. Program Director will conduct chart audits quarterly to confirm ongoing compliance.
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Seven partial hospitalization client records were reviewed on July 26, 2018. The facility failed to document a psychosocial evaluation that included the counselor's documented clinical evaluative statement and recommendations based on information gathered in client histories in records, #1-7.
Client #1 was admitted on 6/1/18 and was an active client at the time of the licensing inspection.
Client #2 was admitted on 6/15/18 and was an active client at the time of the licensing inspection.
Client #3 was admitted on 6/4/18 and was an active client at the time of the licensing inspection.
Client #4 was admitted on 9/1/17 and was discharged on 12/8/17.
Client #5 was admitted on 2/8/18 and was discharged on 4/12/18.
Client #6 was admitted on 1/9/18 and was discharged on 4/12/18.
Client #7 was admitted on 2/28/18 and was discharged on 3/29/18.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will train clinicians on October 10, 2018 on completing a thorough psychosocial evaluation which will include a clear description of the client's presenting and underlying problems; client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment; client assets, strengths, or other factors that can contribute to the resolution of identified problems; the potential or available client support systems; negative factors that might affect treatment; the client's preferred coping mechanisms, conclusions regarding the clients appearance, behavior and reactions during the intake process; and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Active client records were updated to include a thorough psychosocial evaluation including the clinical evaluative statement and recommendations completed by clinicians.
Clinical Director will monitor compliance through chart review during weekly supervision sessions to ensure psychosocial evaluations are thorough. Program Director will conduct chart audits quarterly to confirm ongoing compliance. |
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
Seven partial hospitalization client records were reviewed on July 26, 2018; the facility failed to document that individual sessions were conducted two times per week for clients 1-3.
Client #1 was admitted on 6/1/18 and was an active client at the time of the licensing inspection. Individual sessions were documented only on June 12, June 18, July 2, July 19, 2018.
Client #2 was admitted on 6/15/18 and was an active client at the time of the licensing inspection. Individual sessions were documented only on June 27, July 3, July 9, 2018.
Client #3 was admitted on 6/4/18 and was an active client at the time of the licensing inspection. Individual sessions were documented only on June 8, June 14, June 21, July 2, July 6, July 12, July 16, July 23, 2018.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Staff were retrained on 8/1/18 on the need for two individual sessions per week and documentation of individual sessions. Clinicians will schedule two sessions per week for each participant on their caseload and will document client cancellations. The expectation of two individual sessions per week is also being explained/discussed more thoroughly during the intake sessions by both the Admissions Coordinator and individual Clinicians.
Individual counseling sessions will be provided to each participant on a regular and scheduled basis. The Program Director and Clinical Director will monitor monthly through productivity reports that two individual sessions are provided to each participant each week.
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