INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on November 9, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Renew Family Services, LLC 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) (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.
|
Observations
The facility failed to document the name of the person, agency, or organization to whom the disclosure would be made to on a release of information form in one of six client records reviewed.
Client #4 was admitted on April 22, 2019 and was discharged on September 3, 2019. A release of information form was signed and dated by the client on April 22, 2019.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Director will have a review training with all staff in regard to the required element for a valid release per Pa. DDAP Standard and 42CFR. In order to maintain compliance the Clinical Supervisor will audit Releases on a monthly basis.
The Clinical Supervisor is responsible for maintaining Compliance. |
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
The facility failed to document what specific information was to be released on release of information forms in four of six client records reviewed.
Client # 2 was admitted on December 30, 2019 and was still active at the time of inspection. A release of information form to the emergency contact was signed and dated by the client on December 30, 2019.
Client # 3 was admitted on August 30, 2019 and was still active at the time of inspection. The release of information forms to the pharmacy and to a family member were both signed and dated by the client on August 30, 2019.
Client #4 was admitted on April 22, 2019 and was discharged on September 3, 2019. The release of information forms to the pharmacy and to the emergency contact were both signed and dated by the client on April 22, 2019.
Client #5 was admitted on July 25, 2019 and was discharged on June 23, 2020. The release of information forms to the emergency contact and to a family member were both signed and dated by the client on July 25, 2019.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Director will have a review training with all staff on 11/22/20 in regard to the required elements for a valid release per Pa. DDAP Standard and 42CFR. She will stress the importance of documenting correctly. In order to maintain compliance, the Clinical Supervisor will audit Releases on a monthly basis.
The releases that were documented as incorrect were corrected on 11/17/2020.
The Clinical Supervisor is responsible for maintaining Compliance. |
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.
|
Observations
The facility failed to document the purpose of disclosure on release of information forms in four of six client records reviewed.
Client # 2 was admitted on December 30, 2019 and was still active at the time of inspection. The release of information forms to the pharmacy and to a billing company were both signed and dated by the client on December 30, 2019.
Client # 3 was admitted on August 30, 2019 and was still active at the time of inspection. The release of information forms to billing companies were signed and dated by the client on August 30, 2019.
Client #4 was admitted on April 22, 2019 and was discharged on September 3, 2019. The release of information form to a outside provider was signed and dated by the client on April 22, 2019.
Client #5 was admitted on July 25, 2019 and was discharged on June 23, 2020. The release of information forms to the laboratory and to a billing company were both igned and dated by the client on March 17, 2020. Additionally, a release of information form to second billing company was signed and dated by the client on July 25, 2019.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Director will have a review training with all staff on 11/22/20 in regard to the required elements for a valid release per Pa. DDAP Standard and 42CFR. She will stress the importance of documenting correctly especially the purpose of the release. In order to maintain compliance, the Clinical Supervisor will audit Releases on a monthly basis.
The releases that were documented as incorrect were corrected on 11/17/2020.
The Clinical Supervisor is responsible for maintaining Compliance. |
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
The facility failed to ensure that copies of all release of information forms were offered to the client in four of six client records reviewed.
Client # 1 was admitted on May 26, 2020 and was still active at the time of the inspection. The release of information forms to a family member, to the funding source, to the laboratory, to the billing company and to the pharmacy were all signed and dated by the client on May 26, 2020.
Client # 2 was admitted on December 30, 2019 and was still active at the time of inspection. The release of information form to the laboratory was signed and dated on October 15, 2020. The release of information form to the emergency contact was signed and dated on December 30, 2019. The release of information form to a family member was signed and dated by the client on October 28, 2020.
Client #4 was admitted on April 22, 2019 and was discharged on September 3, 2019. The release of information form to the emergency contact was signed and dated by the client on April 22, 2019.
Client #5 was admitted on July 25, 2019 and was discharged on June 23, 2020. The release of information forms to the primary care physician and to a family member were both signed and dated by the client on July 25, 2019.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Director will have a review training with all staff on 11/22/20 in regard to the rights of the client in regard to releases. All clients shall be offered a copy of the release/s upon signature. In order to maintain compliance, the Clinical Supervisor will audit Releases on a monthly basis in doc u sign.
The releases that were documented as incorrect were corrected on 11/17/2020.
The Clinical Supervisor is responsible for maintaining Compliance. |
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
The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client records reviewed.
Client # 5 was admitted on July 25, 2019 and was administratively discharged on June 23, 2020. There was no documentation in the client record that the client was notified in writing of the decision to involuntarily terminate their treatment at the project.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Director reviewed Renew Family Services Policy with all clinical staff that states the proper procedure for involuntary terminations. Staff were directed to follow the policy to ensure that clients receive written notification of the decision to involuntarily terminate their treatment at Renew. The Clinical Supervisors will audit charts to ensure compliance to this policy and process. The Clinical Director is responsible for Compliance. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
|
Observations
The facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.
Client # 5 was admitted on July 25, 2019 and was administratively discharged on June 23, 2020. There was no documentation in the client records indicating that the client was given the opportunity to request reconsideration of a decision terminating treatment.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Director reviewed Renew Family Services Policy with all clinical staff that states the proper procedure for involuntary terminations. Staff were directed to follow the policy to ensure that clients receive written notification that they can request reconsideration to treatment in regard to their involuntarily termination of treatment at Renew. The Clinical Supervisors will audit charts to ensure compliance to this standard. The Clinical Director is responsible for Compliance. |
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
The facility failed to ensure that all treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of six applicable client records reviewed.
Client # 2 was admitted on December 30, 2019 and was still active at the time of inspection. A treatment plan update was completed on June 16, 2020 with the next update due no later than August 16, 2020; however, the update was completed on October 15, 2020.
Client # 3 was admitted on August 30, 2019 and was still active at the time of inspection. A treatment plan update was completed on January 16, 2020 with the next update due no later than March 16, 2020; however, the update was completed on April 24, 2020.
Client # 5 was admitted on July 25, 2019 and was administratively discharged on June 23, 2020. A treatment plan update was completed on January 17, 2020 with the next update due no later than March 17, 2020; however, the update was completed on May 29, 2020.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Director reviewed Renew Family Services Policy with all clinical staff that states the proper procedure and timeframes (at least every 60 days) for treatment plan updates. Staff were directed to follow the policy to ensure that clients receive exceptional treatment at Renew. The Clinical Supervisors will audit charts to ensure compliance to this policy and process. The Clinical Director is responsible for Compliance. |
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
The facility failed to maintain a complete client record on an individual, which is to include follow-up information, in two of three applicable client records reviewed.
Client #4 was admitted on April 22, 2019 and was discharged on September 3, 2019. There was no follow-up information in the client record at the time of the inspection.
Client #5 was admitted on July 25, 2019 and was discharged on June 23, 2020. There was no follow-up information in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Director reviewed Renew Family Services Policy with all clinical staff that states the proper procedure for following up with a client after discharge. Staff were directed to follow the policy to ensure that clients receive follow up communication and that they document it in the chart. The Clinical Supervisors will audit charts to ensure compliance to this policy and process. The Clinical Director is responsible for Compliance. |