INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 10, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Trehab 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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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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven records reviewed.
Client #1 was admitted on April 17, 2024, and was still active at the time of the inspection. An informed and voluntary consent form was not documented prior to disclosing information to client ' s attorney. There was confirmation in the record that the facility sent a letter disclosing that the client was currently in treatment, dated September 17, 2024.
This finding was discussed with the facility staff during licensing process.
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Plan of Correction
During a clinical staff meeting held on 2/12/2025, consent form protocol was reviewed. Clinicians reviewed the purpose of consent forms, how to correctly complete them in the CMS system, and a reminder to review them in the CMS system before sending a letter of presence or other information on behalf of the client. This review will ensure that client has consented to releasing the requested information. Clinicians are directed to review consents with each client during their next individual sessions and update them as needed. This is to be completed by February 28, 2025. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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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 contained in the client record which included the name of the person, agency or organization to whom disclosure is made in one out of seven records.
Client #7 was admitted on May 15, 2024 and was still active at the time of the inspection. A consent to release information for the emergency contact was signed and dated May 24, 2024, but did not include the name, agency or organization to whom disclosure is made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During a clinical staff meeting held on 2/12/2025, consent form protocol was reviewed. Clinicians reviewed that consent forms need to have specific person or agency identified. In this instance, clinicians reviewed that all emergency contact forms need to have a person or client denial identified on the form. Clinicians are directed to review consents with each client during their next individual sessions and update them as needed. This is to be completed by February 28, 2025. |
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 the clients received counseling services according to their individual treatment and rehabilitation plan in four out of seven applicable records reviewed.
Client #1 was admitted on April 17, 2024, and was still active at the time of inspection. The treatment plan dated April 26, 2024, indicated one individual session weekly. There was no documentation of the client receiving individual therapy for the weeks of June 9-15, 2024, June 30-July 6, 2024, and July 14-20, 2024.
Client #2 was admitted on March 20, 2024 and was discharged on June 28, 2024. The treatment plan dated March 22, 2024, indicated one individual session biweekly and three group sessions weekly. There was no documentation the client received three group sessions for the weeks of May 12-18, 2024, May 19-25, 2024, and June 2-8, 2024.
Client #5 was admitted on May 6, 2024 and discharged on December 19, 2024. The treatment plan dated May 6, 2024, indicated one individual session weekly. There was no documentation of the client receiving individual therapy for the weeks of May 12-18, 2024, and June 30-July 6, 2024.
Client #6 was admitted on June 27, 2024, and was still active at the time of the inspection. The treatment plan dated June 27, 2024, indicated one individual session biweekly and two group sessions weekly. There was no documentation of the client receiving two group sessions for the weeks of August 4-10, 2024, August 18-24, 2024, September 1-7, 2024, September 8-14, 2024, September 15-21, 2024, September 22-28, 2024, or September 29-October 5, 2024.
These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
During a clinical staff meeting held on 2/12/2025, clinicians reviewed the importance of following treatment schedules identified in comprehensive treatment plans. The following protocol will be implemented immediately to ensure that clients meet their treatment schedule identified in their comprehensive treatment plans:
All weekly and bi-weekly clients will be scheduled for two individual sessions at whatever treatment schedule they have agreed to. If a client misses an appointment, all attempts will be made to accommodate their treatment schedule including being seen by another clinician if their primary counselor does not have availability.
This new protocol will be monitored by the clinical supervisor and QM coordinator. |