INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 28, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Treatment and Healing 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:
|
Plan of Correction
|
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
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 contained in the client record. The consent must be in writing and include, but not be limited to, specific information disclosed.
Client #1 was admitted on September 12, 2023, and was still active at the time of the inspection. A release of information form signed and dated October 24, 2023, to probation, did not document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All staff have been retrained in the completion of consents, including the designation of specific information to be disclosed. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician for each level of care. If a consent is found to have errors, the clinician will be given 7 days to have contact with the client and correct the issues. The chart will then be re-reviewed within 10 days. If the consent remains invalid, the staff will be supplied with a 1-1 refresher trainer. If the event occurs 3 or more times, disciplinary action will be taken. Client #1 is scheduled for a 1-1 appt on 9/17/24, at that time, an updated consent will be completed, with the client. |
709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
|
Observations
Based on a review of the client records, the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in the client's record that documented the date, event, or condition upon which the consent will expire in two out of seven records reviewed.
Client #1 was admitted on September 12, 2023, and was still active at the time of the inspection. A release of information form signed and dated September 12, 2023, to an insurance provider, did not document when the consent was to expire.
Client #5 was admitted on April 17, 2024, and was still active at the time of the inspection. A release of information form signed and dated April 19, 2024, to a urine screening facility, did not document when the consent was to expire.
This is a repeat citation from the August 12, 2022 and August 7, 2023, licensing renewal inspections.
These finding were reviewed with the facility staff during the licensing process.
|
Plan of Correction
All staff have been retrained in the completion of consents, including the designation of an assigned expiration date/event/condition for the consent. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician for each level of care. If a consent is found to have errors, the clinician will be given 7 days to have contact with the client and correct the issues. The chart will then be re-reviewed within 10 days. If the consent remains invalid, the staff will be supplied with a 1-1 refresher trainer. If the event occurs 3 or more times, disciplinary action will be taken. Client #1 is schedule for a 1-1 session on 9/17/24 and client #5 on 9/13/24. During those sessions, each client will complete a revised consent. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in four out of seven client records reviewed.
Client #2 was admitted on April 24, 2024, and was still active at the time of the inspection. A release of information form signed and dated April 24, 2024, to juvenile probation, did not document that the client was offered a copy of the consent.
Client #3 was admitted on April 19, 2024, and was discharged on August 16, 2024. A release of information form signed and dated May 3, 2024, to a case worker, did not document that the client was offered a copy of the consent.
Client #5 was admitted on April 17, 2024, and was still active at the time of the inspection. A release of information form signed and dated April 19, 2024, to a urine screening facility did not document that the client was offered a copy of the consent.
Client #7 was admitted on April 5, 2024, and was discharged on June 28, 2024. A release of information form signed and dated April 5, 2024, to juvenile probation, did not document that the client was offered a copy of the consent.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
All staff have been retrained in the completion of consents, including whether or not the client has accepted or declined a copy of the consent. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician for each level of care. If a consent is found to have errors, the clinician will be given 7 days to have contact with the client and correct the issues. The chart will then be re-reviewed within 10 days. If the consent remains invalid, the staff will be supplied with a 1-1 refresher trainer. If the event occurs 3 or more times, disciplinary action will be taken. Client #1 is scheduled for a 1-1 session on 9/17/24 and client #5 on 9/13/24. During those sessions, each client will complete a revised consent. |
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.
|
Observations
Based on a review of client records, the facility failed to 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. This occured in one out of two applicable records reviewed.
Client #3 was admitted on April 19, 2024, and was administratively discharged on August 16, 2024. There was no documentation that the client was notified of this discharge in the client record.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
All staff have been retrained in the discharge process and all forms that are required for discharges, including the use of a treatment termination letter. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician for each level of care. If termination letter is required and missing from the chart, the clinician will be given 7 days to complete and mail the letter. The chart will then be re-reviewed within 10 days. If the letter has not been completed, the staff will be supplied with a 1-1 refresher trainer. If the event occurs 3 or more times, disciplinary action will be taken. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in three out of seven applicable records. The facility's policy notes that a psychosocial evaluation will be completed within thirty days of intake.
Client #4 was admitted on November 11, 2023, and discharged on March 13, 2024. A psychosocial evaluation was completed; however, there was no documentation of a clinical summary in the client record.
Client #5 was admitted on April 17, 2024, and was still active at the time of the inspection. A psychosocial evaluation was comleted; however, there was no documentation of a clinical summary in the client record.
Client #6 was admitted on December 21, 2023, and discharged on April 18, 2024. A psychosocial evaluation was completed; however, there was no documentation of a clinical summary in the client record.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All staff have been retrained in the completion biopsychosocial clinical summary, what it is to include and the timeline parameters in which it must be completed. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician for each level of care. If a summary is found to be missing, incomplete, or not signed by the medical director, the clinician will be given 7 days to address the deficiency. The chart will then be re-reviewed within 10 days. If the deficiency is still present, the staff will be supplied with a 1-1 refresher trainer. If the event occurs 3 or more times, disciplinary action will be taken. Client #5 has a 1-1 session with their clinician on 9/13/24. Following that appt, the clinician will submit a completed biosummary for review and sign off by the doctor. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of four applicable client records.
Client #1 was admitted on September 12, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was completed on October 12, 2023, and the update was due no later than December 12, 2023; however, the next update was completed on February 12, 2024.
Client #2 was admitted on April 24, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 15, 2024, and the update was due no later than July 15, 2024; however, the next update was completed on July 19, 2024.
Client #3 was admitted on April 19, 2024, was discharged on August 16, 2024. A comprehensive treatment plan was completed on May 6, 2024, and the update was due no later than July 6, 2024; however, the next update was completed on July 31, 2024.
Client #6 was admitted on December 21, 2024, was discharged on April 18, 2024. A comprehensive treatment plan was completed on February 9, 2024, and the update was due no later than April 9, 2024; however, the next update was completed on April 18, 2024.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All staff have been retrained in the completion of Treatment Plan Updates, and the mandatory timelines for their completion. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician for each level of care. If a treatment plan is found to be completed outside of the designated timelines, the clinician will be required to document in a progress note, why the treatment plan was late. The clinician will also be supplied with a 1-1 refresher trainer on timelines in reference to treatment plan updates. If the event occurs 3 or more times, after the retraining, disciplinary action will be taken. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of four applicable records reviewed.
Client #1 was admitted on September 12, 2023, and was still active at the time of the inspection. The comprehensive treatment plan dated October 12, 2023, indicated the client would receive one group therapy session per week During the month of July 2024 only one group session was documented in the client record.
Client #2 was admitted on April 24, 2024, and was still active at the time of the inspection. The comprehensive treatment plan dated May 15, 2024, indicated the client would receive one group session per week. During the month of July 2024 only one group session was documented in the client record. Additionally, during the month of August 2024 only one group session was documented in the client record.
Client #3 was admitted on April 19, 2024, and discharged on August 16, 2024. The comprehensive treatment plan dated May 6, 2024, indicated the client would receive one group session per week. During the month of July 2024 only one group session was documented in the client record.
This is a repeat citation from the August 12, 2022 and August 7, 2023, licensing renewal inspections.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All staff have been retrained in the completion of treatment plans, including an accurate reflection of how many times a client is to be seen for group and 1-1 services. Each time a client's number of services is changed, the treatment plan will reflect this. If a client misses a treatment service, there will be a note in the chart reflecting the missed service. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician for each level of care. If a treatment plan is found to have errors or missed service notes are missing, the clinician will be given 7 days to correct the issues. The chart will then be re-reviewed within 10 days. If the issue remains, the staff will be supplied with a 1-1 refresher trainer. If the event occurs 3 or more times, disciplinary action will be taken. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states that a case consultation must be completed within 30, 90, 180, 270 and 365 days of intake.
Client #2 was admitted on April 24, 2024, and was still active at the time of the inspection. The initial case consultation was due no later than May 24, 2024; however, it was not completed until July 30, 2024.
Client #3 was admitted on April 19, 2024, and discharged on August 16, 2024. The initial case consultation was due no later than May 19, 2024; however, there were no case consults documented in the client record.
Client #4 was admitted on November 15, 2023, and was discharged on March 13, 2024. The initial case consultation was due no later than December 15, 2023; however, there were no case consults documented in the client record.
Client #5 was admitted on April 17, 2024, and was still active at the time of the inspection. A ninety-day case consultation was due no later than July 17, 2024; however, there was no case consult documented in the client record.
This is a repeat citation from the August 7, 2023, licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All staff have been retrained in the completion of case consults, including the timelines for completion and what is to be contained within them. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician for each level of care. If a case consult is found to be missing or to have been completed late, the clinician will be given 7 days to complete the case consult, and/or notate why it was completed outside of the assigned timeline. The chart will then be re-reviewed within 10 days. If an issue remains around the case consult, the staff will be supplied with a 1-1 refresher trainer. If the event occurs 3 or more times, disciplinary action will be taken. Client #5 has a session scheduled on 9/13/24. Following that session, the clinician will complete an updated case consult and present to the team. |
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.
|
Observations
Based on a review of residential client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of two applicable discharged records reviewed. The facility's policy is to follow-up with successfully discharged clients within thirty days of discharge.
Client #6 was admitted on December 21, 2023, and was discharged on April 18, 2024. A follow-up contact was to be completed no later than May 18, 2024; however, there was no documentation in the client record that it had been completed.
Client #7 was admitted on April 5, 2024, and was discharged on June 28, 2024. A follow-up contact was to be completed no later than July 28, 2024; however, there was no documentation in the client record that it had been completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The timelines in the policy and procedure manual have been reviewed with staff and training provided on follow up contact. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician for each level of care. If a follow up is found to be missing, the clinician will be given 7 days to have contact with the client, document that client, and notate why the contact was late. The chart will then be re-reviewed within 10 days. If the follow up remains incomplete/unsigned, the staff will be supplied with a 1-1 refresher trainer. If the event occurs 3 or more times, disciplinary action will be taken. |
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.
|
Observations
Based on the review of client records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction for consent to release information forms to include a date, event or condition upon which the consent will expire, was submitted and approved by the Department for the August 12, 2022, and August 7, 2023, annual licensing inspections. Consent to release information forms was again found to be a deficiency in the August 28, 2024 licensing inspection.
Additionally, a plan of correction for clients receiving counseling services according to their individual treatment plans was submitted and approved by the Department for the August 12, 2022, and August 7, 2023, annual licensing inspections. Counseling services was again found to be a deficiency in the August 28, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All staff have been retrained in the completion of consents, including the designation of an expiration date, condition, or event. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician for each level of care. If a consent is found to have errors, the clinician will be given 7 days to have contact with the client and correct the issues. The chart will then be re-reviewed within 10 days. If the consent remains invalid, the staff will be supplied with a 1-1 refresher trainer. If the event occurs 3 or more times, disciplinary action will be taken. |