INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 20, 2020 through October 21, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Sobriety Solutions Pennsylvania 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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704.8(a) LICENSURE Qualifications-Counselor Assistant
704.8. Qualifications for the position of counselor assistant.
(a) A person who does not meet the educational and experiential qualifications for the position of counselor may be employed as a counselor assistant if the requirements of at least one of the following paragraphs are met. However, a project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
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Observations
The project failed to ensure that they did not hire more than one counselor assistant for each employee who meets that requirements of clinical supervisor or counselor. The project only employs three qualified counselors and one qualified clinical supervisor, but employ six counselor assistants
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Sobriety Solutions is now in compliance with DDAP staffing regulations. Sobriety Solutions now maintains a 1:1 ratio of counselor to counselor assistant. Facility Policies have been edited to maintain compliance with DDAP staffing ratios.
Since DDAP Site Visit, two interns have completed their time here, bringing the ratio within regulation. The Director of HR will work with Clinical Director to make sure that in the future the 1:1 staffing ratio is being adhered to. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
The project failed to ensure that a Bachelor's Degree level counselor assistant counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first six months of employment for four out six counselor assistants reviewed.
Employee #5 was employed on May 11, 2020 and was still employed at the time of the inspection. Weekly supervision notes did not document close supervision; specifically, one hour of case review and one hour of direct observation. Additionally, there were no supervision notes for the weeks of July 19, 2020 through July 25, 2020, July 26, 2020 through August 1, 2020, August 2, 2020 through August 8, 2020, August 30, 2020 through September 5, 2020, September 20, 2020 through September 26, 2020 and October 11, 2020 through October 17, 2020.
Employee #6 was employed on August 31, 2020 and was still employed at the time of the inspection. Weekly supervision notes did not document close supervision; specifically, one hour of case review and one hour of direct observation. Additionally, there were no supervision notes for the week of October 4, 2020 through October 10, 2020.
Employee #7 was employed on August 31, 2020 and was still employed at the time of the inspection. Weekly supervision notes did not document close supervision; specifically, one hour of case review and one hour of direct observation.
Employee #8 was employed on August 25, 2020 and was still employed at the time of the inspection. Weekly supervision notes did not document close supervision; specifically, one hour of case review and one hour of direct observation. Additionally, there were no supervision notes for the weeks of August 30, 2020 through September 5, 2020 and October 11, 2020 through October 17, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with the Clinical Staff to review Supervision regulations, guidelines, and requirements. Qualified personnel has been assigned with closely supervising counselor assistants which will include minimum one hour of case review per week and minimum one hour of direct supervision per week. This supervision will be documented in the weekly supervision notes. The clinical supervisor will ensure this is being completed during weekly clinical staff meetings. |
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
The project failed to document an annual written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor in nine of nine personnel records reviewed.
Employee # 1 was employed on May 7, 2018 and was still employed at the time of the inspection.
Employee #2 was employed on June 19, 2019 and was still employed at the time of the inspection.
Employee #3 was employed on June 4, 2019 and was still employed at the time of the inspection.
Employee #4 was employed on September 4, 2019 and was still employed at the time of the inspection.
Employee #5 was employed on May 11, 2020 and was still employed at the time of the inspection.
Employee #6 was employed on August 31, 2020 and was still employed at the time of the inspection.
Employee #7 was employed on August 31, 2020 and was still employed at the time of the inspection.
Employee #8 was employed on August 25, 2020 and was still employed at the time of the inspection.
Employee #9 was employed on September 2, 2020 and was still employed 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 Facility Director, in conjunction with the VP of Operations/HR will develop individual training plans for each type of employee. These will be created with feedback from each individual employee. This plan and feedback will be documented in each employees personnel file. The plans will be reviewed semi-annually for progress, completion, and feedback. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The project failed to ensure that all staff persons received at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in four of six personnel records reviewed.
Employee # 1 was employed on May 7, 2018 and was due to have the communicable disease trainings no later than May 7, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #2 was employed on June 19, 2019 and was due to have the communicable disease trainings no later than June 19, 2020. There was no documentation in the personnel file of the TB/STD training as of the date of the inspection.
Employee #3 was employed on June 4, 2019 and was due to have the communicable disease training no later than June 4, 2020. There was no documentation in the personnel file of the TB/STD training as of the date of the inspection.
Employee #4 was employed on September 4, 2019 and was due to have the communicable disease training no later than September 4, 2020. There was no documentation in the personnel file of the TB/STD training as of the date of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and Vp of Operations have revised the required Staff Trainings to include 4hrs of DDAP approved STD/TB training. All current employees will complete training by 12/31/2020. All futre employees will be required to complete training within 6 months of hire. The Vp of Operations will work with the Director of HR to ensure these trainings are being completed. HR chats will be audited monthly to check for completion. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The project failed to ensure that a sufficient number of staff persons were trained in first aid, so that at least one person trained in these skills were onsite during the project's hours of operation. Based on the review of the Staffing Requirement Facility Summary Report and personnel records, there was no documentation of any staff member completing first aid training in nine of nine personnel records reviewed.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Sobriety Solutions will conduct mandatory CPR and First Aid training for all employees. This will be held on site by an American Red Cross certified trainer. Training is to be held during the week of 12/7/2020. As per the CEO, All employees will be required to attend. Future employees will be required to attend CPR/First Aid Training within 6 months of hire. The Vp of Operations will work with the Director of HR to ensure these trainings are completed. Hr chart audits will be performed monthly to check for any missing trainings. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to ensure that all staff were instructed in the use of the fire extinguisher upon staff employment in four of nine personnel records reviewed.
Employee #5 was employed on May 11, 2020 and was due to receive instruction in the use of the fire extinguisher no later than May 19, 2020. There was no documentation in the personnel file indicating that the employee was trained in the use of the fire extinguisher.
Employee #6 was employed on August 31, 2020 and was due to receive instruction in the use of the fire extinguisher no later than September 8, 2020. There was no documentation in the personnel file indicating that the employee was trained in the use of the fire extinguisher.
Employee #7 was employed on August 31, 2020 and was due to receive instruction in the use of the fire extinguisher no later than September 8, 2020. There was no documentation in the personnel file indicating that the employee was trained in the use of the fire extinguisher.
Employee #8 was employed on August 25, 2020 and was due to receive instruction in the use of the fire extinguisher no later than September 2, 2020. There was no documentation in the personnel file indicating that the employee was trained in the use of the fire extinguisher.
Employee #9 was employed on September 2, 2020 and was due to receive instruction in the use of the fire extinguisher no later than September 10, 2020. There was no documentation in the personnel file indicating that the employee was trained in the use of the fire extinguisher.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Employees of Sobriety Solutions have been trained on proper use of fire extinguisher. Employee Onboarding Process has been edited to include this training. Going forward, new employees will be trained during HR orientation process. This will occur within first 3 days of employment. The Director of HR will be responsible for ensuring all employees are up to date with mandatory safety training. HR chart audits will be done at the end of each month to check for any overdue trainings, this will be done by the Director of HR. If a training is due, it will be scheduled at the earliest possible time slot. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to wnsure that all staff were trained to perform assigned tasks during emergencies in four of nine personnel records reviewed.
Employee #5 was employed on May 11, 2020 and was due to receive training to perform assigned tasks during emergencies no later than May 19, 2020. There was no documentation in the personnel file indicating that the employee was trained to perform assigned tasks during emergencies.
Employee #6 was employed on August 31, 2020 and was due to receive training to perform assigned tasks during emergencies no later than September 8, 2020. There was no documentation in the personnel file indicating that the employee was trained to perform assigned tasks during emergencies.
Employee #7 was employed on August 31, 2020 and was due to receive training to perform assigned tasks during emergencies no later than September 8, 2020. There was no documentation in the personnel file indicating that the employee was trained to perform assigned tasks during emergencies.
Employee #8 was employed on August 25, 2020 and was due to receive training to perform assigned tasks during emergencies no later than September 2, 2020. There was no documentation in the personnel file indicating that the employee was trained to perform assigned tasks during emergencies.
Employee #9 was employed on September 2, 2020 and was due to receive training to perform assigned tasks during emergencies no later than September 10, 2020. There was no documentation in the personnel file indicating that the employee was trained to perform assigned tasks during emergencies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All employees have completed Emergency Evacuation Training and are now aware of assigned tasks during emergencies. Emergency Evacuation Training has been added to the New Employee Onboarding Process. The Safety Officer will be responsible for ensuring assigned tasks are being completed during Fire Drills. Emergency evacuation training will be held quarterly. Trainings will be held by the appointed Safety Officer and acknowledged by all in attendance. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
This is a repeat citation from the January 24, 2020 licensure renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As stated in previous citation, Organization sought to complete 2019 audit by mid 2020. However, due to Covid related shutdown Organization was unable to complete this. As per previous POC, audit for 2020 will be completed at end of fiscal year. Exemption to submit tax return has been filed, organization is awaiting response. The CEO will work with the CFO to ensure that this is completed. If exception is granted, a tax return for 2019 will be submitted. If exception is not granted, the CEO and CFO will schedule audit for both 2019 and 2020. |
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
The project failed to include the name of the perosn, agency, or organization to whom disclosure would be made to on an informed and voluntary consent to release information form contained in the client record in two of fourteen client records reviewed.
Client #4 was admitted on March 2, 2020 and was discharged on March 31, 2020. A release of information form, signed and dated by the client on March 2, 2020, did not include the name of the person, agency or organization documented on the form.
Client #5 was admitted on May 18, 2020 and was discharged on June 29, 2020. A release of information form, signed and dated by the client on March 18, 2020, did not include the name of the person, agency or organization documented on the form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The VP of Operations has worked with the EMR company to require all release forms be filled out completely. This is to include name of person, agency, or organization to whom release is being made to. The EMR system will no longer allow a release to be completed without this required information. The Clinical Director will check all consents and releases during weekly clinical chart audit. Any missing information will be corrected within 3 business days. |
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
The project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in fourteen of fourteen client records reviewed.
Client #1 was admitted on September 28, 2020 and was a current client at the time of the inspection. A release of information form to a funding source, signed and dated by the client on September 28, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #2 was admitted on September 28, 2020 and was a current client at the time of the inspection. A release of information form to a funding source, signed and dated by the client on September 28, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to an employer, signed by the client on September 28, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #3 was admitted on August 24, 2020 and was a current client at the time of the inspection. A release of information form to a funding source, signed and dated by the client on August 24, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #4 was admitted on March 2, 2020 and was discharged on March 31, 2020. A release of information form to a funding source, signed and dated by the client on March 2, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #5 was admitted on May 18, 2020 and was discharged on June 29, 2020. A release of information form to a funding source, signed and dated by the client on May 18, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information to a probation agency, signed and dated by the client on May 18, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #6 was admitted on August 21, 2020 and was discharged on September 14, 2020. A release of information form to a funding source, signed and dated by the client on August 21, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on February 19, 2020 and was discharged on March 3, 2020. A release of information form to a funding source, signed and dated by the client on February 19, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #8 was admitted on April 24, 2020 and was a current client at the time of the inspection. A release of information form to a funding source, signed and dated by the client on April 24, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #9 was admitted on August 7, 2020 and was a current client at the time of the inspection. A release of information form to a funding source, signed and dated by the client on August 7, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #10 was admitted on July 13, 2020 and was a current client at the time of the inspection. A release of information form to a funding source, signed and dated by the client on July 13, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #11 was admitted on February 26, 2020 and was discharged on July 29, 2020. A release of information form to a funding source, signed and dated by the client on February 26, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #12 was admitted on April 13, 2020 and was discharged on August 24, 2020. A release of information form to a funding source, signed and dated by the client on April 13, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #13 was admitted on February 13, 2020 and was discharged on July 2, 2020. A release of information form to a funding source, signed and dated by the client on February 13, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #14 was admitted on March 16, 2020 and was discharged on September 18, 2020. A release of information form to a funding source, signed and dated by the client on March 16, 2020, that allowed for the release of treatment plans, psychiatric history and assessments, results of physical exam, medical history/current status, biopsychosocial, lab test results, employment information, legal status, family information, aftercare, recommendation, discharge planning and summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will hold confidentiality training on 11/16/2020 for all clinical and admissions staff. This training will review what information can be disclosed to different types of releases.
All clinical and admissions employees, as per the CEO, will be required to attend DDAP approved confidentiality training within 6 months. New employees will be required to attend within 6 months of hire.
The VP of Operations has worked with the EMR company to create more specific release forms which are specific to the various types of releases.
The Clinical Director will check all consents and releases during weekly clinical chart audit. Any incorrect info will be corrected within 3 business days. |
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
The project failed to document that a copy of a client consent was offered to the client in fourteen of fourteen client records reviewed.
Client #1 was admitted on September 28, 2020 and was a current client at the time of the inspection. There was no documentation that the client was offered a copy of any of the release of information forms signed by the client on September 28, 2020.
Client #2 was admitted on September 28, 2020 and was a current client at the time of the inspection. There was no documentation that the client was offered a copy of any of the release of information forms signed by the client on September 28, 2020.
Client #3 was admitted on August 24, 2020 and was a current client at the time of the inspection. There was no documentation that the client was offered a copy of any of the release of information forms signed by the client on August 24, 2020.
Client #4 was admitted on March 2, 2020 and was discharged on March 31, 2020. There was no documentation that the client was offered a copy of any of the release of information forms signed by the client on March 2, 2020.
Client #5 was admitted on May 18, 2020 and was discharged on June 29, 2020. There was no documentation that the client was offered a copy of any of the release of information forms signed by the client on May 18, 2020.
Client #6 was admitted on August 21, 2020 and was discharged on September 14, 2020. There was no documentation that the client was offered a copy of any of the release of information forms signed by the client on August 21, 2020.
Client #7 was admitted on February 19, 2020 and was discharged on March 3, 2020. There was no documentation that the client was offered a copy of any of the release of information forms signed by the client on February 19, 2020.
Client #8 was admitted on April 24, 2020 and was a current client at the time of the inspection. There was no documentation that the client was offered a copy of any of the release of information forms signed by the client on April 24, 2020.
Client #9 was admitted on August 7, 2020 and was a current client at the time of the inspection. There was no documentation that the client was offered a copy of any of the release of information forms signed by the client on August 7, 2020.
Client #10 was admitted on July 13, 2020 and was a current client at the time of the inspection. There was no documentation that the client was offered a copy of any of the release of information forms signed by the client on July 13, 2020.
Client #11 was admitted on February 26, 2020 and was discharged on July 29, 2020. There was no documentation that the client was offered a copy of any of the release of information forms signed by the client on February 26, 2020.
Client #12 was admitted on April 13, 2020 and was discharged on August 24, 2020. There was no documentation that the client was offered a copy of any of the release of information forms signed by the client on April 13, 2020.
Client #13 was admitted on February 13, 2020 and was discharged on July 2, 2020. There was no documentation that the client was offered a copy of any of the release of information forms signed by the client on February 13, 2020.
Client #14 was admitted on March 16, 2020 and was discharged on September 18, 2020. There was no documentation that the client was offered a copy of any of the release of information forms signed by the client on March 16, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will work with VP of Operations and EMR provider(KIPU) to add attestation on all consent forms. The attestation will allow client to accept or reject copy of consent. This attestation has been set to require client signature and also witness signature. If client accepts copy, a copy will be printed and supplied to the client. All current clients have been notified of the revision and offered copies of consents. All future clients will be required to sign attestation on each consent signed. |
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
The project failed to document that the client had acknowledged that they were notified that they have the right to inspect their own records, 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, and that the reasons for removing sections shall be documented in the record in fourteen of fourteen client records reviewed.
Client #1 was admitted on September 28, 2020 and was a current client at the time of the inspection.
Client #2 was admitted on September 28, 2020 and was a current client at the time of the inspection.
Client #3 was admitted on August 24, 2020 and was a current client at the time of the inspection.
Client #4 was admitted on March 2, 2020 and was discharged on March 31, 2020.
Client #5 was admitted on May 18, 2020 and was discharged on June 29, 2020.
Client #6 was admitted on August 21, 2020 and was discharged on September 14, 2020.
Client #7 was admitted on February 19, 2020 and was discharged on March 3, 2020.
Client #8 was admitted on April 24, 2020 and was a current client at the time of the inspection.
Client #9 was admitted on August 7, 2020 and was a current client at the time of the inspection.
Client #10 was admitted on July 13, 2020 and was a current client at the time of the inspection.
Client #11 was admitted on February 26, 2020 and was discharged on July 29, 2020.
Client #12 was admitted on April 13, 2020 and was discharged on August 24, 2020.
Client #13 was admitted on February 13, 2020 and was discharged on July 2, 2020.
Client #14 was admitted on March 16, 2020 and was discharged on September 18, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client Rights form was revised to include the following:
"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."
This has been updated in Policy & Procedure Manual, wall hangings, Client Handbook, and the Client Acknowledgement of Rights(signed during intake).
All current clients have signed updated acknowledgement. All future clients will sign updated acknowledgement. The client rights acknowledgement is required to be signed during intake by both admitting client as well as witness.
The admissions team member who completes admission will ensure consent to client rights is signed during intake process. The Clinical Director will check to ensure that this has been done during weekly clinical chart audits. |
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
The project failed to document the client acknowledgement that they were notified that they have the right to appeal a decision limiting access to their records to the director in fourteen of fourteen client records reviewed.
Client #1 was admitted on September 28, 2020 and was a current client at the time of the inspection.
Client #2 was admitted on September 28, 2020 and was a current client at the time of the inspection.
Client #3 was admitted on August 24, 2020 and was a current client at the time of the inspection.
Client #4 was admitted on March 2, 2020 and was discharged on March 31, 2020.
Client #5 was admitted on May 18, 2020 and was discharged on June 29, 2020.
Client #6 was admitted on August 21, 2020 and was discharged on September 14, 2020.
Client #7 was admitted on February 19, 2020 and was discharged on March 3, 2020.
Client #8 was admitted on April 24, 2020 and was a current client at the time of the inspection.
Client #9 was admitted on August 7, 2020 and was a current client at the time of the inspection.
Client #10 was admitted on July 13, 2020 and was a current client at the time of the inspection.
Client #11 was admitted on February 26, 2020 and was discharged on July 29, 2020.
Client #12 was admitted on April 13, 2020 and was discharged on August 24, 2020.
Client #13 was admitted on February 13, 2020 and was discharged on July 2, 2020.
Client #14 was admitted on March 16, 2020 and was discharged on September 18, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client Rights form was revised to include the following:
"Clients have the right to appeal a decision limiting access to their records to the director"
This has been updated in Policy & Procedure Manual, wall hangings, Client Handbook, and the Client Acknowledgement of Rights(signed during intake).
All current clients have signed updated acknowledgement. All future clients will sign updated acknowledgement.The client rights acknowledgement is required to be signed during intake by both admitting client as well as witness.
The admissions team member who completes admission will ensure consent to client rights is signed during intake process. The Clinical Director will check to ensure that this has been done during weekly clinical chart audits. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
The project failed to document the client acknowledgement that they were notified that they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in fourteen of fourteen client records reviewed.
Client #1 was admitted on September 28, 2020 and was a current client at the time of the inspection.
Client #2 was admitted on September 28, 2020 and was a current client at the time of the inspection.
Client #3 was admitted on August 24, 2020 and was a current client at the time of the inspection.
Client #4 was admitted on March 2, 2020 and was discharged on March 31, 2020.
Client #5 was admitted on May 18, 2020 and was discharged on June 29, 2020.
Client #6 was admitted on August 21, 2020 and was discharged on September 14, 2020.
Client #7 was admitted on February 19, 2020 and was discharged on March 3, 2020.
Client #8 was admitted on April 24, 2020 and was a current client at the time of the inspection.
Client #9 was admitted on August 7, 2020 and was a current client at the time of the inspection.
Client #10 was admitted on July 13, 2020 and was a current client at the time of the inspection.
Client #11 was admitted on February 26, 2020 and was discharged on July 29, 2020.
Client #12 was admitted on April 13, 2020 and was discharged on August 24, 2020.
Client #13 was admitted on February 13, 2020 and was discharged on July 2, 2020.
Client #14 was admitted on March 16, 2020 and was discharged on September 18, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client Rights form was revised to include the following:
"Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records"
This has been updated in Policy & Procedure Manual, wall hangings, Client Handbook, and the Client Acknowledgement of Rights(signed during intake).
All current clients have signed updated acknowledgement. All future clients will sign updated acknowledgement.The client rights acknowledgement is required to be signed during intake by both admitting client as well as witness.
The admissions team member who completes admission will ensure consent to client rights is signed during intake process. The Clinical Director will check to ensure that this has been done during weekly clinical chart audits. |
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
The project failed to document the client acknowledgement that they were notified that they have the right to submit rebuttal data or memoranda to their own records in fourteen of fourteen client records reviewed.
Client #1 was admitted on September 28, 2020 and was a current client at the time of the inspection.
Client #2 was admitted on September 28, 2020 and was a current client at the time of the inspection.
Client #3 was admitted on August 24, 2020 and was a current client at the time of the inspection.
Client #4 was admitted on March 2, 2020 and was discharged on March 31, 2020.
Client #5 was admitted on May 18, 2020 and was discharged on June 29, 2020.
Client #6 was admitted on August 21, 2020 and was discharged on September 14, 2020.
Client #7 was admitted on February 19, 2020 and was discharged on March 3, 2020.
Client #8 was admitted on April 24, 2020 and was a current client at the time of the inspection.
Client #9 was admitted on August 7, 2020 and was a current client at the time of the inspection.
Client #10 was admitted on July 13, 2020 and was a current client at the time of the inspection.
Client #11 was admitted on February 26, 2020 and was discharged on July 29, 2020.
Client #12 was admitted on April 13, 2020 and was discharged on August 24, 2020.
Client #13 was admitted on February 13, 2020 and was discharged on July 2, 2020.
Client #14 was admitted on March 16, 2020 and was discharged on September 18, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client Rights form was revised to include the following:
"Clients have the right to submit rebuttal data or memoranda to their own records"
This has been updated in Policy & Procedure Manual, wall hangings, Client Handbook, and the Client Acknowledgement of Rights(signed during intake).
All current clients have signed updated acknowledgement. All future clients will sign updated acknowledgement. The client rights acknowledgement is required to be signed during intake by both admitting client as well as witness.
The admissions team member who completes admission will ensure consent to client rights is signed during intake process. The Clinical Director will check to ensure that this has been done during weekly clinical chart audits.
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709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
The project failed to document preliminary treatment and rehabilitation plans during intake in five of seven client records reviewed.
Client #1 was admitted on September 28, 2020 and was a current client at the time of the inspection.
Client #2 was admitted on September 28, 2020 and was a current client at the time of the inspection.
Client #4 was admitted on March 2, 2020 and was discharged on March 31, 2020.
Client #5 was admitted on May 18, 2020 and was discharged on June 29, 2020.
Client #7 was admitted on February 19, 2020 and was discharged on March 3, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New Client Intake procedure has been amended to include preliminary treatment and rehabilitation plans.
All clinical and admissions staff memebers were trained on the new procedure.
Training on this new procedure was held during weekly staff meeting on 10/30/2020.
Upon intake, all clients will now receive preliminary treatment and rehabilitation plans. This plan will be developed by the clinical director during the process of approval for admittance.
The Director of Operations has worked with the EMR company to make the Preliminary Treatment plan a mandatory completion for the intake process. The Clinical Director will check for completion during weekly clinical chart audits. |