INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 28, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mid-Atlantic Rehabilitation Services - A.T.P. 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, conducted November 28, 2017 at approximately 2:45 pm, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room as there was a see-through sheer curtain in group room 3 hanging in the window facing the parking lot.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will ensure replacement of curtain with appropriate blind by 12/31/2017. During quarterly safety inspections Director will check all window coverings to ensure appropriate privacy. |
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 14 patient records, the facility failed to keep disclosures of patient identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in 1 record reviewed.
Client # 2 was admitted on 12/12/16 and was an active client at the time of inspection. A consent to release information form to the probation officer, signed by the client on 12/12/16. However, the consent allowed for the release of urine screens, assessment results, treatment plans, aftercare plans and discharge summary. Additionally, there was a consent to release information form to a government agency, signed by the client on 12/12/16. Howeever, the consent allowed for the release of urine screens, assessment results, treatment plans, aftercare plans and discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will work with clinicians involved in client #2's case to complete corrected releases and by 1/31/2018 in-service trainings conducted by the Director and clinical Supervisor on 255.5 will be conducted with all staff of the agency. The agencies Quality Assurance team will conduct 10% audits of all active records release of information forms for the next 6 months to ensure 255.5 is followed in completion of releases. |
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.
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Observations
Based on a review of 7 outpatient client records, 4 records had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.
Client #1 was admitted on 5/25/17 and was an active client at the time of inspection. An initial treatment plan was completed 5/25/17 and the update was due no later than 7/25/17. However, the next update was not completed until 11/6/17.
Client #2 was admitted on 12/7/16 and was active at the time of inspection. A treatment plan update was completed 2/21/17 and the next update was due no later than 4/21/17. However, the next update was not completed until 7/18/17. Additionally, a treatment plan update was completed 7/18/17 and the next update was due no later than 9/18/17. However, the next update was not completed until 10/10/17.
Client #6 was admitted on 7/18/16 and was discharged on 2/1/17. A treatment plan update was completed 8/15/16 and the next update was due no later than 10/15/16. However, the next update was not completed until 11/4/16.
Client #7 was admitted on 6/27/17 and was discharged on 10/14/17. A treatment plan was completed 7/13/17 and the next update was due no later than 9/13/17. However, the next update was not completed until 9/22/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director and Clinical Supervisor will conduct in-service training with all staff in regards to treatment plan updates and regulatory guidelines and agency policies and procedures in order to ensure timely completion of treatment plan updates by 1/31/2018. The Quality Assurance team will conduct a 10% audit of all active records for 6 months to ensure completion within guidelines of treatment plan updates. |