INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5, 2022 through January 6, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Libertae Family House Libertae, Inc. 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the facility ' s training feedback policy and seven personnel records, the facility failed to ensure that employees completed training feedback forms within three days of the training in one record.Employee #1 was hired as the Project and Facility Director on May 4, 2015 and has remained in that position. The personnel file contained three blank training feedback forms for the training period reviewed.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency shall be corrected by the following steps:
According to the training feedback policy, the facility shall ensure that employees complete training feedback forms within three days of the training.
It is the responsibility of the administrative office track employee attendance at trainings. Once an employee completes a scheduled training, the administrative office manager shall issue a training feedback form to that employee for completion. A training certificate will only be issued to the employee once the feedback form has been returned to the administrative office manager.
The administrative office manager shall maintain a spreadsheet of all employees with a list of mandatory trainings that are to be completed within the expected time frames. Also included on the spreadsheet is a list of all documents required for employment. The training feedback forms shall be included on this list.
It is the responsibility of the administrative office manager to maintain the correction of this deficiency. This will be completed by reviewing all personnel binders upon employment, and biannually thereafter, at 6 months and 12 months. Any deficiencies noted shall be brought to the attention of the employee's supervisor for 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 ensure that each employee had a training plan for the current training year, which began July 1, 2021, in seven of seven records reviewed.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency shall be corrected by the following steps:
The missing training plans for the staff records identified shall be completed and filed in the respective personnel records by 02/25/2022.
The facility shall ensure that each employee has a training plan developed upon hire and updated annually. The plans shall be maintained in the employee's personnel record.
Each supervisor will meet with their respective employees annually, prior to the start of the new year, July 1st. They will discuss the employee's training goals for the upcoming year. The Individual Training Plan document will be completed and returned to the supervisor for approval.
Once approved, the supervisor shall submit the Individual Training Plan form to the administrative office manager for inclusion in the employee's personnel binder.
The administrative office manager shall maintain a spreadsheet of all employees with a list of mandatory trainings that are to be completed within the expected time frames. Also included on the spreadsheet is a list of all documents required for employment. The Individual Training Plan shall be included on this list.
It is the responsibility of the administrative office manager to maintain the correction of this deficiency. This will be completed by reviewing all personnel binders upon employment, and biannually thereafter, at 6 months and 12 months. Any deficiencies noted shall be brought to the attention of the employee's supervisor for correction. |
705.5 (f) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(f) A bedroom may not be used as a means of egress from or access to another part of the facility.
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Observations
Based on a physical plant inspection on January 6, 2022, the facility failed to ensure that a bedroom was not a means of egress from the facility. The bedroom in the lower level of the Crossroads building had a sliding door leading outside. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The sliding door in the bedroom at Crossroads that leads to the outside of the building shall be removed and replaced with a window.
The time frame for completion of this renovation is 06/30/2022.
The person responsible for oversight of this renovation is the Director of Operations.
No clients shall reside in this bedroom until the renovation has been completed and approved by DDAP licensing. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on January 6, 2022, the facility failed ensure that either individual paper towels or a mechanical dryer was in each of the client bedrooms in the Family House building.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Paper towel receptacles have now been installed in each bathroom where they were missing, either shared or individual, in the residential facility (Family House).
All operations staff have been made aware of the need to maintain the receptacles and keep them filled with paper towels. Any operations staff who notice that the receptacles are empty or not in good repair, shall notify maintenance personnel by placing a work order in the facilities management system (NetFacilities), and identify the location in need of attention.
It is the responsibility of the maintenance personnel to ensure the receptacles are in good working order and to replace the paper products on a routine, regular basis.
The Director of Operations, who oversees the line staff and maintenance personnel shall conduct a monthly inspection of residents' bathrooms to ensure that the correction is maintained. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on documentation provided by the facility, the facility failed to conduct unannounced fire drills at least once a month, as no fire drills were conducted in the Halfway House building during the 2021 months of June, July, August, and December.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected and the plan of correction is ongoing, as outlined below:
Maintenance personnel will schedule unannounced drills in advance for a calendar year for all residential facilities - Family House, Halfway House, Crossroads.
Operations staff shall be trained and will perform unannounced fire drills in these buildings, as scheduled.
A Fire Safety Log shall be maintained, to include date, time, place and census (including number of women, children, visitors, and staff) in the facility at the time of the drill.
Exits that are blocked and routes taken for evacuation shall be documented in the Fire Safety Log, as well as time the alarm was sounded until the last person was evacuated from the building.
Any deficiencies noted in the log by the Director of Operations, or any missed drills will be addressed with the staff responsible. Corrective actions will be taken immediately, to include updated trainings, and not to exclude disciplinary actions.
The Maintenance Manager, in cooperation with the Director of Operations, will review the Fire Safety Logs monthly, in order to review and maintain compliance after each drill.
Monthly drills will be conducted, even in unoccupied buildings, to maintain and ensure the fire alarms and detectors are operational.
Outcomes and evaluations of the Fire Safety Plan will be reviewed with operations staff on a monthly basis in departmental meetings.
The Director of Operations is responsible for the Fire Safety Plan. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the March 2021 through November 2021 fire drill logs the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.Regarding the fire drill logs for the Family House, the facility failed to document if the alarm was operative in April, June, July, August, September, and October. The amount of time to evacuate was not documented in July, August, September, or October. The exit route used was not recorded in the May, July, August, September, and October logs. The complete number of persons in the facility was not recorded in May, July, August, September, October, or November. Whether the fire alarm or smoke detector was operative was not recorded in April, June, July, August, September, or October.Fire drill logs for the Halfway House building for June, July and August as well as each month reviewed for the Crossroads building were missing the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered, and whether the fire alarm or smoke detector was operative.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected and the plan of correction is ongoing as outlined below:
1. Maintenance personnel shall schedule unannounced drills in advance for a calendar year for all three buildings - Family House, Halfway House and Crossroads.
2. Operations staff shall e trained and shall perform unannounced fire drills in the three buildings.
3. The Fire Safety Log shall include date, time, place and census including number of women, children, staff and visitors in the facility at the time of the drill.
4. Exits that are blocked and routes taken for evacuation shall be documented on the log as well as time of the alarm sounded to last person evacuated from the building.
5. Any deficiency in the log or missed drill will be addressed with the staff and corrective actions shall be taken immediately.
6. Outcomes and evaluations of drills will be reviewed by the Director of Operations with operations staff on a monthly basis at departmental staff meetings.
7. Monthly drills will continue to be in effect, even in unoccupied buildings to maintain and ensure the fire alarms and detectors are operational.
8. The maintenance manager in collaboration with the Operations Director will review the Fire Safety Logs to determine compliance with the protocols after each drill.
The Fire Safety Plan is the responsibility of the Director of Operations. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from March 2021 through November 2021, the facility failed to prepare alternate exit routes in the Halfway House building as the same exit route was documented in each drill.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected.
The maintenance personnel have posted alternate routes to evacuation in each building.
Methods of egress will be reviewed with the operations staff who conduct fire drills prior to the monthly drills.
Exits that are blocked and routes taken for evacuation will be documented on the Fire Drill Log as well as the time the alarm was sounded, to the last person evacuated from the building.
Outcomes and evaluations of drills will be reviewed by the Director of Operations with operations staff on a monthly basis at departmental staff meetings.
The Fire Safety Plan is the responsibility of the Director of Operations. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection on January 6, 2022, the facility failed to maintain protective caps over each electrical outlet in the bathrooms located on the Family House floor as well as on a power strip in the lounge of the Family House.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected.
The power strip which does not have protective caps, found upon inspection in the Family House lounge, was removed and replaced with a power strip that has child proof closing covers.
All electric outlets in the Family House have been outfitted with child proof safety outlet closing covers.
All GFR outlets in the family house bathrooms have been outfitted with a childproof plate for closure when not in use.
The correction will be maintained by taking the following action steps:
1. The Facility Director will disseminate the Building and Grounds Policy and Procedures and review procedures with operations department personnel, to include the need to ensure that protective caps must be in place over each electrical outlet located in the bathrooms of the Family House floor (resident sleeping area) and the Family House lounge.
2. All staff will be directed to enter a work order in the facility management system should they identify any area of the buildings and grounds that need attention, including findings issues with electrical outlet protective covers.
3. It is the responsibility of maintenance personnel to respond to all work orders in the facilities management system in a timely manner.
4. All grounds of the facility will be inspected monthly by maintenance personnel who are to ensure that the electrical outlets are covered with protective caps in the Family House bathrooms (residents' quarters).
5. The Director of Operations or the Facility Director shall review with maintenance personnel all work orders entered into the facility management system and the resolution of same on a monthly basis.
6. The management team of the facility will develop and implement written standard work procedures for maintenance services that are organized to include all areas for improvement that have been identified by this inspection.
7. The Facility Director will generate and disseminate data reports that demonstrate improvements in the area of physical plant.
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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 seven client records, the facility failed to ensure that consent to release information forms included the specific information to be disclosed in one record reviewed.Client #3 was admitted on February 17, 2021 and was discharged June 12, 2021. The record contained a consent to release information form to an outside party signed by the client on February 25, 2021 that was missing the specific information to be disclosed.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been addressed by the following:
The consent to release information form must include specific information to be disclosed. The staff person completing this consent form for Client #3 has been retrained on this procedure. All records will be reviewed for completeness, adequacy and accuracy at regularly scheduled meetings with supervisor.
The correction shall be maintained by the Social Services Director, who supervises the respective employee. |
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 seven client records, the facility failed to ensure that consent to release information forms included the purpose of disclosure in three records reviewed.Client #1 was admitted on March 26, 2021 and was discharged June 2, 2021. The record contained a consent to release information form to a family member signed by the client on March 30, 2021 that was missing the purpose of disclosure.Client #6 was admitted on October 12, 2021 and was an active client at the time of inspection. The record contained a consent to release information form to a Probation Officer signed by the client on December 14, 2021 that was missing the purpose of disclosure. Client #7 was admitted on December 8, 2021 and was an active client at the time of inspection. The record contained consent to release information form to a Probation Officer, and two other legal entities signed by the client on December 9, 2021, December 10, 2021 and December 21, 2021 that were missing the purpose of disclosure. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected by the following procedures:
The consent to release information form must include the purpose of disclosure. The staff person who completed the consent forms for Client #1, Client #6 and Client #7 has been retrained on this procedure. Records will be reviewed for completeness, adequacy and accuracy at regularly scheduled meetings with supervisor. Client #7 is currently in treatment; therefore an updated release form will be completed and uploaded to client's record by February 18, 2022.
It is the responsibility of the Social Services Director to implement and maintain this correction. |
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 seven client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in one record reviewed.Client #7 was admitted on December 8, 2021 and was active at the time of the inspection. The record contained a consent to release information form to a lab signed by the witness on December 8, 2021, that was missing the dated signature of the client.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected by the following procedures:
The consent to release information form must include the dated signature of a client. The staff person who completed the consent form for Client #7 has been retrained on this procedure. Records will be reviewed for completeness, adequacy and accuracy at regularly scheduled meetings with supervisor. Client #7 is currently in treatment; therefore an updated release form will be completed and uploaded to client's record by February 18, 2022.
It is the responsibility of the Director of Social Services to implement and maintain this correction. |
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.
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the date, event, or condition upon which the consent will expire in three records reviewed.Client #5 was admitted on October 27, 2021 and was active at the time of inspection. The record contained consent to release information forms to the funding source, pharmacy, lab, and a family member signed by the client on October 27, 2021 that were missing the date, event, or condition upon which the consent will expire.Client #6 was admitted on October 12, 2021 and was active at the time of inspection. The record contained consent to release information forms to the funding source, pharmacy, lab, an outside provider, and the emergency contact signed by the client on October 12, 2021 that were missing the date, event, or condition upon which the consent will expire.Client #7 was admitted on December 8, 2021 and was active at the time of inspection. The record contained consent to release information forms to the funding source, pharmacy, lab, and a family member signed by the client on December 8, 2021 that were missing the date, event, or condition upon which the consent will expire.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected by the following procedures:
The consent to release information form must include the date, event, or condition upon which the consent will expire. The staff person who completed these forms has now been retrained on this procedure. Records will be reviewed for completeness, adequacy and accuracy at regularly scheduled meetings with supervisor. Client #7 is currently in treatment; therefore a new consent form will be completed which includes expiration date, event or condition and will be uploaded to client file by February 18, 2022.
it is the responsibility of the Director of Social Services to implement and maintain this correction. |
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 seven client records, the facility failed to ensure that clients were offered a copy of signed consent to release information forms in five records reviewed.Client #1 was admitted on March 26, 2021 and was discharged June 2, 2021. The record contained a consent to release information form to a family member signed by the client on March 30, 2021, which did not indicate that the client was offered a copy. Client #3 was admitted on February 17, 2021 and was discharged June 12, 2021. The record contained a consent to release information form to an outside party signed by the client on February 25, 2021, which did not indicate that the client was offered a copy.Client #4 was admitted on May 17, 2021 and was discharged on August 9, 2021. The record contained a consent to release information form to a family member signed by the client on May 17, 2021, which did not indicate that the client was offered a copy.Client #6 was admitted on October 12, 2021 and was an active client at the time of inspection. The record contained a consent to release information form to a Probation Officer signed by the client on December 14, 2021, which did not indicate that the client was offered a copy.Client #7 was admitted on December 8, 2021 and was an active client at the time of inspection. The record contained consent to release information form to a Probation Officer, and two other legal entities signed by the client on December 9, 2021, December 10, 2021 and December 21, 2021, which did not indicate that the client was offered a copy. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected by the following procedures:
The consent to release information form must indicate that a copy of the consent was offered to the client. The staff person completing these forms with Client #1, Client #3, Client #4, Client #6 and Client #7 has now been retrained on this procedure. Records will be reviewed for completeness, adequacy and accuracy at regularly scheduled meetings with supervisor. Client #7 is currently in treatment; therefore a new consent form will be completed indicating if client accepted or refused copy will be uploaded to client file by February 18, 2022.
It is the responsibility of the Director of Social Services to implement and maintain this correction. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, in three of seven records reviewed.Client #5 was admitted on October 27, 2021 and was active at the time of inspection. Client #6 was admitted on October 12, 2021 and was active at the time of inspection.Client #7 was admitted on December 8, 2021 and was active at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected.
The Client Bill of Rights has been edited to include the required language that the project may not discriminate in the provision of services "on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion". (Item #16)
Active clients who had not been informed, shall be informed by 02/25/2022. The manager of admissions will be responsible for this notification and to file the document in the respective clients' charts.
Updated copies of the Client Bill of Rights have been added to admission documents for distribution to clients.
The Program Manager is responsible for maintaining the templates of all documents used in the client records.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including that the project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record, in three of seven records reviewed. Client #5 was admitted on October 27, 2021 and was active at the time of inspection. Client #6 was admitted on October 12, 2021 and was active at the time of inspection.Client #7 was admitted on December 8, 2021 and was active at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected.
The Client Bill of Rights has been edited to include the required language that the "project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record." (Item #14)
Active clients who had not been informed, shall be informed by 02/25/2022. The manager of admissions will be responsible for this notification and to file the document in the respective clients' charts.
Updated copies of the Client Bill of Rights have been added to admission documents for distribution to clients.
The Program Manager is responsible for maintaining the templates of all documents used in the client records.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including that clients have the right to appeal a decision limiting access to their records to the director, in three of seven records reviewed. Client #5 was admitted on October 27, 2021 and was active at the time of inspection. Client #6 was admitted on October 12, 2021 and was active at the time of inspection.Client #7 was admitted on December 8, 2021 and was active at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected.
The Client Bill of Rights has been edited to include the required language that "clients have the right to appeal a decision limiting access to their records to the director". (Item #14)
Active clients who had not been informed, shall be informed by 02/25/2022. The manager of admissions will be responsible for this notification and to file the document in the respective clients' charts.
Updated copies of the Client Bill of Rights have been added to admission documents for distribution to clients.
The Program Manager is responsible for maintaining the templates of all documents used in the client records. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including that clients have the right to submit rebuttal data or memoranda to their own records, in three of seven records reviewed. Client #5 was admitted on October 27, 2021 and was active at the time of inspection. Client #6 was admitted on October 12, 2021 and was active at the time of inspection.Client #7 was admitted on December 8, 2021 and was active at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected.
The Client Bill of Rights has been edited to include the required language that "clients have the right to submit rebuttal data or memoranda to their own records". (Item #14)
Updated copies of the Client Bill of Rights have been added to admission documents for distribution to clients.
Active clients who had not been informed, shall be informed by 02/25/2022. The manager of admissions will be responsible for this notification and to file the document in the respective clients' charts.
The Program Manager is responsible for maintaining the templates of all documents used in the client records. |
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 seven client records, the facility failed to ensure a complete client record that included psychosocial evaluations for four client records reviewed. Client #2 was admitted on March 3, 2021 and was discharged on May 6, 2021.Client #4 was admitted on May 17, 2021 and was discharged on August 9, 2021.Client #5 was admitted on October 27, 2021 and was active at the time of inspection. Client #6 was admitted on October 12, 2021 and was active at the time of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the policy of Libertae to ensure that a complete client record is maintained. This includes psychosocial evaluations, which are to be completed within 30 days of admission. The psychosocial evaluation is signed and dated by the clinical director, psychiatrist and therapist of record and added to the client file.
In cases where the client has not completed the psychosocial evaluation for any reason, such as an abrupt discharge from treatment, a note will be made in the client's record, on the psychosocial evaluation form.
This deficiency has been corrected by the clinical director who has advised the therapists of the requirement, and implemented a record review procedure.
The correction will be maintained by the clinical director, who will review each client's file within the 30 day time frame for entering the psychosocial evaluation into the record. The clinical director utilizes an audit checklist to account for documentation. This checklist is reviewed quarterly by the Quality Assurance committee of the facility. Corrective action will be taken whenever a deficiency is noted. |
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 seven client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in five records reviewed.Client #2 was admitted on March 3, 2021 and was discharged on May 6, 2021. The comprehensive treatment plan completed on April 3, 2021 indicated the frequency of individual sessions to be weekly; however, no individual sessions were documented as being held between April 8, 2021 and May 3, 2021.Client #3 was admitted on February 17, 2021 and was discharged on June 12, 2021. The comprehensive treatment plan and subsequent treatment plan updates completed on and after March 23, 2021 indicated the frequency of individual sessions to be weekly; however, no individual sessions were documented as being held during the weeks of March 22, 2021, May 17, 2021, and May 31, 2021.Client #4 was admitted on May 17, 2021 and was discharged on August 9, 2021. The comprehensive treatment plan completed on June 16, 2021 indicated the frequency of individual sessions to be weekly; however, no individual sessions were documented as being held between June 21, 2021 and July 19, 2021.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the policy of Libertae to ensure that counseling services are provided according to the individual treatment and rehabilitation plans of the respective client. The comprehensive treatment plan shall indicate the frequency of individual sessions.
In cases where the client has missed an individual treatment session, for any reason, this shall be documented in a DAP note (data, action, plan) in the client record as "0" (zero) minutes, followed by the reason for missing the individual session. Each DAP note will include the follow up plan as to how the therapist of record will address the missed session with the client.
This deficiency has been corrected by the clinical director who has advised the therapists of the requirement, and implemented a record review procedure.
The correction will be maintained by the clinical director, who will review each client's file within at 30, 60, 90 and 120 days of the client's treatment episode. The clinical director utilizes an audit checklist to account for documentation. This checklist is reviewed quarterly by the Quality Assurance committee of the facility. Corrective action will be taken whenever a deficiency is noted.
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