INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 3, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Interim House West 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide documentation that written individual training plans were developed annually and with input from both the employee and the supervisor in one of two applicable personnel records reviewed.
Employee # 2 was hired as a clinical supervisor on May 4, 2023. The individual training plan was signed by the supervisor on May 4, 2023, but there was no documentation that the plan was developed with input from the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and employee #2 will meet to discuss training plan and training plan will be complete by 9/30/23. Program Director will monitor all individual training plan to ensure that employee is in compliant with regulation 704.11. The individual training plan will be developed by the employee and the employee will meet with their supervisor to discuss the individual training plan within five days of their employment. a tracking system will be used to ensure that individual training plans are address. Throughout the employee employment Individual training plans will be reviewed and documented. |
705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection, conducted on August 3, 2023 between 10:00 AM and 10:45 AM, the facility failed to ensure that all bunk beds were equipped with securely attached railings on each side and open end of the bunk.
In each family overflow suite, there were bunk beds that had a mesh bed rail that was not securely attached to the bed. The bed rail did not securely attach to the bed and there were large open areas on either side of the bed rail.
This deficiency was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors will be trained by the Program Director on 705.5 (b) Sleeping accommodations. Training will be completed by 9/30/2023. A copy of the training completion and staff participating will be kept on file in the Program Director's Office.
IHW Program Director, with assistance from the PHMC BHS Admin Program Manager will conduct a search for vendors with beds meeting the 705.5 (b) regulatory requirements. This search will be completed by 9/30/2023. Upon review of vendors, IHW will select a vendor for the new beds in the family overflow suites. Selection will be completed by October 31, 2023. Upon selection of the new beds for the family overflow suites, the beds will be ordered and installed by PHMC facilities department. Ordering and Installation will be completed by November 30, 2023.
During regular (e.g. daily) room checks, Resident Assistants will review that beds are according to 705.5 sleeping accommodation regulatory requirements and will provide a written report daily to the IHW Facility Manager. The IHW facility manager will report any issues to the Program Director for internal Plan of Correction, and will create and send any correction issues to PHMC facilities when appropriate.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in two of two applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Client # 5 was admitted on September 12, 2022 and was discharged against medical advice on May 22, 2023. There was no documentation in the record that the emergency contact was notified of the discharge against medical advice.
Client # 7 was admitted on February 16, 2023 and was discharged against medical advice on April 24, 2023. There was no documentation in the record that the emergency contact was notified of the discharge against medical advice.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Program Director will meet with clinical staff to review facility policy on client leaving treatment against medical advice by September 30, 2023. The Clinical Director and Program Director will conduct Inservice training to clinical and non-clinical staff to ensure that are aware of the discharge policy and procedures by September 30, 2023. This Inservice training will also focus on documentation of the emergency contact was notified of the discharged. The Clinical Director and/or the on-call Clinical staff (per on-call program schedule) will be notified by resident assistant staff immediately after a program participant leaves against medical advice/ against facility advice. The Clinical Director and/or the on-call Clinical staff will oversee that the emergency contact on file for the program participant, with appropriate Release of Information also on file, is notified within 12 hours after the program participant's discharge AMA/AFA, and documented as a service note in the client chart.
During regular (e.g. quarterly) Compliance reviews of client charts, the PHMC Compliance Department will check Service Notes to ensure that the emergency contacts were notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21. The PHMC Compliance Department will report any issues of non-compliance with this requirement to the Program Director for internal correction.
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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 document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form in one of seven client records reviewed.
Client # 1 was admitted on November 3, 2022 and was still active at the time of the inspection. There was a blank, undated release of information form signed by the client in the record; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
This is a repeat citation from the August 12, 2021 and August 17, 2022 annual licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors will be trained by the Program Director on the 709.28 (c) (1) Confidentiality requirement, including that 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.
IHW Therapists and/or Case Manager will review existing client files per their caseload to ensure that all Consents for Release of Information (ROI) include the Name of the person, agency or organization to whom disclosure is made. ROI documentation that does not include the Name of the person, agency or organization to whom disclosure is made will be re-done with the program participant so that a proper ROI is in the client file that is valid and complete. This corrective action will be completed for all active program participants by 9/30/2023.
As part of the Individualized Staff Training Plan development, within 30 days of hire, supervisors will instruct every staff member assigned to them to complete a DDAP Approved Confidentiality Training Course within 365 days of hire, which includes information about obtaining Consent for Release of Information.
During regular (e.g. quarterly) client file reviews, The PHMC Compliance Department will monitor that complete and valid ROI documentation is present in the official client record, including that consent must be in writing and include, but not be limited to: Name of the person, agency or organization to whom disclosure is made. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors will be trained on this plan of correction by the Program Director by 9/30/2023.
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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.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in two of seven client records reviewed.
Client # 1 was admitted on November 3, 2022 and was still active at the time of the inspection. There was a blank, undated release of information form signed by the client in the record that failed to include the specific information to be disclosed.
Client # 2 was admitted on October 5, 2022 and was still active at the time of the inspection. A release of information form to an outside agency was signed by the client on March 24, 2023; however, the form did not include the specific information to be disclosed.
This is a repeat citation from the August 17, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors will be trained by the Program Director on the 709.28 (c) (2) Confidentiality requirement, including that consent must be in writing and include, but not be limited to: (2) Specific information disclosed.
IHW Therapists and/or Case Management will review existing client files to ensure that all Consents for Release of Information (ROI) include Specific information disclosed. ROI documentation that does not include Specific information disclosed will be re-done with the program participant so that a proper ROI is in the client file that is valid and complete. This corrective action will be completed for all active program participants by 9/30/2023.
As part of the Individualized Staff Training Plan development, within 30 days of hire, supervisors will instruct every staff member assigned to them to complete a DDAP Approved Confidentiality Training Course within 365 days of hire, which includes information about obtaining Consent for Release of Information.
During regular (e.g. quarterly) client file reviews, The PHMC Compliance Department will monitor that complete and valid ROI documentation is present in the official client record, including that consent must be in writing and include, but not be limited to: Specific information disclosed. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors will be trained by the Program Director on this plan of correction by 9/30/2023.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a release of information form in one of seven client records reviewed.
Client # 1 was admitted on November 3, 2022 and was still active at the time of the inspection. There was a blank, undated release of information form signed by the client in the record; however, the form did not include the purpose of the disclosure.
This is a repeat citation from the August 12, 2021 and August 17, 2022 annual licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors will be trained by the Program Director on the 709.28 (c) (3) Confidentiality requirement, including that consent must be in writing and include, but not be limited to: (3) Purpose of disclosure.
IHW Case Management and/or Therapists will review existing client files to ensure that all Consents for Release of Information (ROI) include Purpose of disclosure. ROI documentation that does not include Purpose of disclosure will be re-done with the program participant so that a proper ROI is in the client file that is valid and complete. This corrective action will be completed for all active program participants by 9/30/2023.
As part of the Individualized Staff Training Plan development, within 30 days of hire, supervisors will instruct every staff member assigned to them to complete a DDAP Approved Confidentiality Training Course within 365 days of hire, which includes information about obtaining Consent for Release of Information.
During regular (e.g. quarterly) client file reviews, The PHMC Compliance Department will monitor that complete and valid ROI documentation is present in the official client record, including that consent must be in writing and include, but not be limited to: Purpose of disclosure. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors will be trained on this plan of correction by the Program Director by 9/30/2023.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in one of seven client records reviewed.
Client # 1 was admitted on November 3, 2022 and was still active at the time of the inspection. There was a blank release of information form signed by the client in the record; however, the release form did not include the dated signature of the client.
This is a repeat citation from the August 17, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors will be trained by the Program Director by September 30, 2023 on the 709.28 (c) (4) Confidentiality requirement, including that consent must be in writing and include, but not be limited to: (4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
IHW Case Management and/or Therapists will review existing client files to ensure that all documentation of Consent for Release of Information (ROI) include Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients). ROI documentation that does not include Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients) will be re-done with the program participant so that a proper ROI is in the client file that is valid and complete. This corrective action will be completed for all active program participants by 9/30/2023.
As part of the Individualized Staff Training Plan development, within 30 days of hire, supervisors will instruct every staff member assigned to them to complete a DDAP Approved Confidentiality Training Course within 365 days of hire, which includes information about obtaining Consent for Release of Information.
During regular (e.g. quarterly) client file reviews, The PHMC Compliance Department will monitor that complete and valid ROI documentation is present in the official client record, including that consent must be in writing and include, but not be limited to: Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients). The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors will be trained by the Program Director on this plan of corrective by 9/30/2023.
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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.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client for each release of information form in one of seven client records reviewed.
Client # 1 was admitted on November 3, 2022 and was still active at the time of the inspection. There was a blank, undated release of information form signed by the client in the record; however, there was no documentation that a copy of the consent form was offered to the client.
This is a repeat citation from the August 17, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors will be trained by the Program Director by September 30, 2023 on the 709.28 (d) Confidentiality requirement, including that A copy of a client consent shall be offered to the client and a copy maintained in the client record.
IHW Case Management and/or Therapists will review existing client files to ensure that all documentation of Consent for Release of Information (ROI) include that a copy of a client consent was offered to the client and a copy maintained in the client record.
ROI documentation that does not include that a copy of a client consent was offered to the client and a copy maintained in the client record, will be re-done with the program participant so that a proper ROI is in the client file that is valid and complete. This corrective action will be completed for all active program participants by 9/30/2023.
As part of the Individualized Staff Training Plan development, within 30 days of hire, supervisors will instruct every staff member assigned to them to complete a DDAP Approved Confidentiality Training Course within 365 days of hire, which includes information about obtaining Consent for Release of Information.
During regular (e.g. quarterly) client file reviews, The PHMC Compliance Department will monitor that complete and valid ROI documentation is present in the official client record, including that a copy of a client consent was offered to the client and a copy maintained in the client record. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors will be trained by the Program Director on this plan of corrective by 9/30/2023.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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, the facility failed to document, as part of their intake and admissions process, a timely psychosocial evaluation of the client in five of seven client records reviewed.
The facility policy and procedure manual states that the psychosocial evaluation is to be completed within 30 days of admission.
Client # 1 was admitted on November 3, 2022 and was still active at the time of the inspection. There was no psychosocial evaluation of the client documented in the record at the time of the inspection.
Client # 2 was admitted on October 4, 2022 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed by November 5, 2022; however, the evaluation was not completed until November 10, 2022.
Client # 3 was admitted on November 9, 2022 and was still active at the time of the inspection. There was no psychosocial evaluation of the client documented in the record at the time of the inspection.
Client # 4 was admitted on November 16, 2022 and was discharged on February 27, 2023. The psychosocial evaluation was due to be completed by December 16, 2022; however, the evaluation was not completed until December 22, 2022.
Client # 7 was admitted on February 16, 2023 and was discharged on April 24, 2023. There was no psychosocial evaluation of the client documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Program Director with review and update all missing initial bio -psychosocial evaluation stated inspection report 9/30/2023. Going forward each new client will receive a bio-psychosocial evaluation during the initial intake. The admission coordinator will complete the initial intake on the day of admission. The Clinical Director will review and sign-off on the Bio-psychosocial the day of intake to ensure compliance of regulation 709.51. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 document a timely individual treatment and rehabilitation plan, which is to be developed with the client, in six of seven client records reviewed.
The facility policy and procedure manual states the individual treatment and rehabilitation plan will be completed within 30 days of admission.
Client # 2 was admitted on October 4, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by November 5, 2023; however, the plan was completed on November 10, 2022.
Client # 3 was admitted on November 9, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by December 9, 2022; however, the plan was completed on January 12, 2023.
Client # 4 was admitted on November 16, 2022 and was discharged on February 27, 2023. The individual treatment and rehabilitation plan was due to be completed by December 16, 2022; however, the plan was completed on December 28, 2022.
Client # 5 was admitted on September 9, 2022 and was discharged on May 22, 2023. The individual treatment and rehabilitation plan was due to be completed by October 9, 2022; however, the plan was completed on February 8, 2023.
Client # 6 was admitted on September 16, 2022 and was discharged on February 28, 2023. The individual treatment and rehabilitation plan was due to be completed by October 16, 2022; however, the plan was completed on October 25, 2022.
Client # 7 was admitted on February 16, 2023 and was discharged on April 24, 2023. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By September 30, 2023, the Clinical Director will conduct an in-service with clinical staff to review 709.52 (a) received comprehension treatment plan be complete timely. The training will address the importance of all clients entering treatment receive a treatment plan on the correct due date. Clinical Director will ensure that individual treatments plans are review during weekly supervision with therapist and during weekly treatment team conference.
During regular (e.g. quarterly) client file reviews, The PHMC Compliance Department will monitor that complete and valid individual treatment and rehabilitation plan documentation is present in the official client record. The Compliance Department will report any findings to the Program Director for internal Plan of Correction. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every thirty days in five of six applicable client records reviewed.
Client # 2 was admitted on October 4, 2022 and was still active at the time of the inspection. A treatment plan update was completed on January 5, 2023 and the next update was due no later than February 5, 2023; however, the update was not completed until February 14, 2023. Additionally, a treatment plan update was completed on May 5, 2023 and the next update was due no later than June 5, 2023; however, the update was not completed at the time of the inspection.
Client # 3 was admitted on November 9, 2022 and was still active at the time of the inspection. A treatment plan update was completed on May 11, 2023 and the next update was due no later than June 11, 2023; however, the update was not completed until July 11, 2023.
Client # 4 was admitted on November 16, 2022 and was discharged on February 27, 2023. A treatment plan update was completed on January 17, 2023 and the next update was due no later than February 17, 2023; however, the update was not completed at the time of discharge.
Client # 5 was admitted on September 9, 2022 and was discharged on May 22, 2023. A treatment plan update was completed on April 7, 2023 and the next update was due no later than May 7, 2023; however, the update was not completed at the time of discharge.
Client # 6 was admitted on September 16, 2022 and was discharged on February 28, 2023. The individual treatment and rehabilitation plan was completed on October 25, 2022 and the first update was due no later than November 25, 2022; however, the update was not completed until December 15, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By September 30, 2023, the Clinical Director, therapist and program director will update all active clients recovery plans stated in deficiency report. Clinical Director will also conduct an in-service with clinical staff to review 709.52 (c) received comprehension treatment plan within the first thirty days of treatment and thereafter of every thirty days. The training will address the importance of all clients entering treatment receiving preliminary treatment plan, thirty-day treatment plan and there after every thirty days until end of treatment. Clinical Director will ensure that individual treatment is review and updated every thirty days thought-out participant stay.
During regular (e.g. quarterly) client file reviews, The PHMC Compliance Department will monitor that complete and valid Treatment and rehabilitation plan documentation is present in the official client record. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 being provided according to the individual treatment and rehabilitation plan in three of five applicable client records reviewed.
Client # 1 was admitted on November 3, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on December 5, 2022 and all the subsequent treatment plan updates, indicated that the client was to receive weekly individual counseling sessions. There were no individual counseling sessions documented in the client record during the month of July 2023. Additionally, there was only 3 individual counseling sessions documented during each of the months of June 2023, May 2023, and April 2023.
Client # 2 was admitted on October 4, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on November 10, 2022 and all the subsequent treatment plan updates, indicated that the client was to receive weekly individual counseling sessions. There were no individual counseling sessions documented in the client record during the month of July 2023. Additionally, there was only 3 individual counseling sessions documented during each of the months of March 2023, February 2023, and November 2023 and one individual counseling session documented during the months of June 2023 and January 2023.
Client # 4 was admitted on November 16, 2022 and was discharged on February 27, 2023. The individual treatment and rehabilitation plan, completed on December 28, 2022 and the subsequent treatment plan update, indicated that the client was to receive weekly individual counseling sessions. There was only one individual counseling session documented during the entire treatment episode of the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By September 30, 2023, the Clinical Director will conduct an in-service with clinical staff to review 709.52 (c) to ensure that individual session is completed according to their individual treatment and rehabilitation plan, with all clients who are entering and or participant in treatment. The therapist will complete individual progress notes to document actions and progress of the client's relation to the treatment. The Clinical Director will monitor that counseling services were being provided to program participants according to their individual treatment and rehabilitation plans during weekly clinical treatment team meetings or during regular (e.g. weekly) individual clinical staff supervision meetings.
During regular (e.g. quarterly) client file reviews, The PHMC Compliance Department will monitor that counseling services were being provided according to the individual treatment and rehabilitation plan and that documentation is present in the official client record. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include case consultation notes, in three of six applicable client records reviewed.
Client # 1 was admitted on November 3, 2022 and was still active at the time of the inspection. There were no case consultation notes documented in the client record at the time of the inspection.
Client # 2 was admitted on October 4, 2022 and was still active at the time of the inspection. There were no case consultation notes documented in the client record at the time of the inspection.
Client # 3 was admitted on November 9, 2022 and was still active at the time of the inspection. There were no case consultation notes documented in the client record at the time of the inspection.
This is a repeat citation from the August 17, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By September 30, 2023, clinical director, therapist and program director will update all active clients case consultation stated the the inspection report. The Clinical Director will also conduct an in-service with clinical staff to review 709.53 (c) to ensure case consultations will be completed every 90 days for the clients in the program the case consultation will address date of consultation, multidisciplinary treatment team, review client progress in treatment and summary of the of the discussion and disposition of the case.
The Clinical Director will monitor that case consultation notes were being completed for program participants during weekly clinical treatment team meetings or during regular (e.g. weekly) individual clinical staff supervision meetings.
During regular (e.g. quarterly) client file reviews, The PHMC Compliance Department will monitor that case consultation were being completed and documented per the requirement in the official client record. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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 a complete client record, which is to include follow-up information, in two of four applicable client records reviewed.
Client # 4 was admitted on November 16, 2022 and was discharged on February 27, 2023. There was no follow-up information documented in the client record at the time of the inspection.
Client # 7 was admitted on February 16, 2023 and was discharged on April 24, 2023. There was no follow-up information documented in the client record at the time of the inspection.
This is a repeat citation from the August 17, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By September 30, 2023, the Clinical Director and Program Director will conduct an in-service with the Case Mangers to review the 709.53 follow-up policy in which a discharge clients will receive follow up contacts and on the use of the follow-up contact form after program completion and/or discharge. During weekly Supervision, the clinical director will ensure that discharged clients are being followed-up by the case managers as per policy.
During regular (e.g. quarterly) client file reviews, The PHMC Compliance Department will monitor that complete and valid follow-up documentation is present in the official client record. The Compliance Department will report any findings to the Program Director for internal Plan of Correction. |
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 administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to document the name of the person, agency, or organization to whom the disclosure is made on consent to release information forms was submitted and approved by the Department for the August 12, 2021 and August 17, 2022 annual licensing inspections. Failing to document the name of the person, agency, or organization to whom the disclosure is made on consent to release information forms was again found to be a deficiency in the August 3, 2023 licensing inspection.
A plan of correction for failing to document the purpose of the disclosure on release of information forms was submitted and approved by the Department for the August 12, 2021 and August 17, 2022 annual licensing inspections. Failing to document the purpose of the disclosure on release of information forms was again found to be a deficiency in the August 3, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors will be trained by the Program Director on the 709.17(a)(3) LICENSURE Subchapter B. Licensing Procedures requirements, including that The Department may revoke or refuse to issue a license for any of the following reasons: 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.
The Program Director will monitor that plans of correction are being implemented as written and submitted to the Department. The Program Director will review Plans of Correction submitted to the Department with the program staff responsible for implementing the Plans of Correction during regular (e.g. weekly) supervision meetings with the Clinical Director and the Facility Manager and the Registered Nurse. Non-compliance with Plans of Correction will be reported by the Program Director to the PHMC Managing Director of Addiction Services for appropriate follow-up. Non-compliance and follow-up will be documented in the staff's supervision notes and/or Performance Evaluations following the guidelines of PHMC's staff disciplinary policies and procedures. |