INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 6, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, American Treatment Network was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide a written individual training plan for each employee, that documented it was developed annually in four out of eight personnel records reviewed.
Employee # 1 was hired as the Project Director on January 1, 2021. The most recent individual training plan was completed on January 18, 2021.
Employee # 3 was hired as the clinical supervisor on January 18, 2021. The most recent individual training plan was completed on January 22, 2022.
Employee # 4 was hired as a counselor on March 28, 2022. The most recent individual training plan was completed on April 8, 2022.
Employee # 6 was hired as a counselor on March 8, 2022. The most recent individual training plan was completed on April 6, 2022.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
- On 11/3/23, The Facility Director submitted a Wavier to DDAP to remove employee # 1 as Project Director. The current Facility Director will be the new Project Director. The current Clinical Supervisor will be promoted to the new Clinical Director.
- The requirements of the Project and Facility Director have been documented in the staff training plans and signed by both the Project and Facility Director. This will be done on an annual basis.
- On 11/2/23, The Facility Director and employee #3 have jointly discussed and reviewed the staff development training plan to properly identify the appropriate skills needed for the position as well as the personal development expressed by employee #3
- This has been documented in the staffing training plan and signed off by both the Facility Director and employee #3.
- Facility Director and employee #3 will review this plan monthly and annually (based on hire date) to document any changes or addition needed for business or professional development purposes.
- On 11/1/23, The Clinical Supervisor and employee #4 jointly discussed and reviewed the staff development training plan to properly identify the appropriate skills needed for the position as well as the personal development expressed by employee #4.
- This has been documented in the staffing training plan and signed off by both the Clinical Supervisor and employee #4.
- Facility Director and employee #4 will review this plan monthly and annually (based on hire date) to document any changes or addition needed for business or professional development purposes.
- Facility Director and employee #6 will review this plan monthly and annually (based on hire date) to document any changes or addition needed for business or professional development purposes.
- This has been documented in the staffing training plan and signed by both the Facility Director and employee #6.
- Facility Director and employee #6 will review this plan monthly and annually (based on hire date) to document any changes or addition needed for business or professional development purposes.
- Compliance Director to hold monthly QA meetings with staff and leaders to review and document corrective actions' progress or lack of progress towards DDAP standards.
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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
Based on a review of eight personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that two employees received the minimum of 4 hours of TB/STD training and 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee # 1 was hired as the Project Director on January 1, 2021 and was due to have the communicable disease trainings no later than January 1, 2023. However, there was no documentation of the completion of the TB/STD or HIV/AIDS trainings as of the date of the inspection.
Employee # 4 was hired as a counselor on March 28, 2022 and was due to have the communicable disease trainings no later March 28, 2023. However, there was no documentation of the completion of the TB/STD or HIV/AIDS trainings as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The Clinical Supervisor provided employee # 1 and employee # 4 with available dates for HIV and TB/STD training.
- Completion date for this training is due by 1/3/24.
- These Trainings have been documented on the staff development plan and signed off by both the Clinical Supervisor and employee #1 and #4.
- Compliance Director to hold monthly QA meetings with staff and leaders to review and document corrective actions' progress or lack of progress towards DDAP standards.
Facility Director will document and add certificates of the completed training to the HR files for employee #1, and employee # 4.
- TB/STD or HIV/AIDS training courses have been included in the staff development plans for all other staff.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director.
Employee # 1 was hired as Project Director on January 1, 2021 and has remained in that position. The facility's training year that was reviewed was from January 1, 2022 through December 31, 2022. Employee # 1's employee record only documented 2.25 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- On 11/3/23, The Facility Director submitted a Wavier to DDAP to remove employee # 1 as Project Director. The current Facility Director will be the new Project Director. The current Clinical Supervisor will be promoted to the new Clinical Director.
- The requirements of the Project and Facility Director, including at least 12 clock hours of training annually in specific areas identified in the standard, have been documented in the staff training plans and signed by both the Project and Facility Director. This will be done on an annual basis.
- On 11/2/23, The Facility Director and employee #1 have jointly discussed and reviewed the staff development training plan to properly identify the appropriate skills needed for the position as well as the personal development expressed by employee #1.
- This has been documented in the staffing training plan and signed off by both the Facility Director and employee #1.
- Facility Director and employee #1 will review this plan monthly and annually (based on hire date) to document any changes or addition needed for business or professional development purposes.
- Compliance Director to hold monthly QA meetings with staff and leaders to review and document corrective actions' progress or lack of progress towards DDAP standards.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 fire drill logs from November 2022 through September 2023, the facility failed to ensure that fire drill logs included the exit route used for each fire drill conducted.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The Facility Director has added the exit route used to the fire drill documentation log to meet this standard.
- The Compliance Director will perform monthly audits at the facility to ensure exit routes are being used for each fire drill conducted.
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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
Based on an administrative review, the facility 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.
The project had a Department-approved exception, per Licensing Alert 01-11, however, the project's most recent tax return verified gross earnings that exceeded the maximum amount allowed in the Alert.
This is a repeat citation from the October 14, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The General Manager will 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.
The Facility Director will monitor that the financial audit is being completed to prevent this citation from happening again. |
709.28 (c) 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.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client # 3 was admitted to the Outpatient level of care on January 9, 2023 and was discharged on March 21, 2023. The record contained documentation of a disclosure of information to a government agency on February 9, 2023, and the record contained no client signed consent to release information form to the agency. Additionally, the record contained documentation of a disclosure of information to a parole agent on February 22, 2023; however, the client did not sign a consent to release information form to the parole agent until February 24, 2023.
Client # 4 was admitted to the Outpatient level of care on December 19, 2022 and was discharged on May 1, 2023. The record contained documentation of a disclosure of information to a government agency on February 17, 2023, and the record contained no client signed consent to release information form to the agency.
This is a repeat citation from the October 14, 2022 and December 1, 2021 annual licensure renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The Facility Director will create a new release in the EHR for DHSS to be used and signed by the appropriate client. ? 11/27/23 -
- The Clinical Director will train staff on the new DHSS release and the requirement of disclosure to ensure staff are not communicating information without an active signed consent by the client.
-The Clinical Director and the Clinical Supervisor will train staff on 11/21/2023 on all releases and the process regarding obtaining releases before any disclosure to any third-party including probation officers.
- The Compliance Director will develop an orientation checklist for staff to utilize to include all the required consent to release information forms.
- The Compliance Director will conduct a monthly audit on 20% of new admissions and current clients to ensure all clients are reviewing and signing all the appropriate consents and releases are signed before any information can or will be disclosed.
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709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of 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 # 6 was admitted to the Outpatient level of care on May 9, 2023 and was active at the time of the inspection. The record contained a consent to release information form to the funding source that was not signed or dated by the client.
This is a repeat citation from the October 14, 2022 annual licensure renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The Clinical Director conducted training for all staff on the requirements for Confidentiality to ensure all clients have the appropriate consents signed.
- The Clinical Supervisor conducted hands-on training on how to provide consents, including funding source for clients performing virtual sessions. This training has been documented and signed by staff.
- The Clinical Director will audit new admissions for consent and confidentiality compliance.
- The Compliance Director will develop an orientation checklist for staff to utilize that will include all the required consent to release information forms, including the funding source for clients to review and sign.
- The Compliance Director will audit at least 10% of all active client charts for compliance.
-Client #6 has a scheduled appointment on 11/16/2023 and consent will be signed on that date and be documented in the EMR system.
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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of seven client records, the facility's intake procedures failed to include documentation of disclosure to the client of criteria for admission, treatment, or completion in all seven records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The Clinical Director or Facility Director will provide an orientation checklist and program welcome packet which includes program expectations, criteria for admission, treatment, completion, and discharge for new clients entering the program.
- The checklist and welcome packet will be documented and signed by the client and staff as evidence of meeting this requirement.
- The Clinical Supervisor will audit and document 25% of new admissions to measure compliance.
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in six records reviewed.
Client # 2 was admitted on October 19, 2022 and was discharged on September 26, 2023. The individual treatment and rehabilitation plan was completed on November 2, 2022; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on January 9, 2023 and was discharged on March 21, 2023. The individual treatment and rehabilitation plan was completed on January 11, 2023; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on December 19, 2022 and was discharged on May 1, 2023. The individual treatment and rehabilitation plan was completed on December 19, 2022; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 5 was admitted on March 22, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 22, 2023; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on May 9, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 9, 2023; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 7 was admitted on July 20, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 8, 2023; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- On 11/14/23 - The Clinical Supervisor and Clinical Director will conduct a treatment plan training based on the DDAP standards during group and to make sure all staff are documenting the type and frequency of treatment and rehabilitation services.
- The Clinical Supervisor and/or Clinical Director will also provide and document individual supervision as well as view treatment plans during the session to verify compliance.
- The Clinical Supervisor will audit 10% of all charts each month to verify this requirement is being consistently met.
- The Compliance Director will audit at least 10% of new admissions and current clients to ensure treatment plans document the type and frequency of services.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in four of seven client records reviewed.
Client # 2 was admitted on October 19, 2022 and was discharged on September 26, 2023. The individual treatment and rehabilitation plan was completed on November 2, 2022; however, the plan did not include documentation of the proposed type of support services.
Client # 3 was admitted on January 9, 2023 and was discharged on March 21, 2023. The individual treatment and rehabilitation plan was completed on January 11, 2023; however, the plan did not include documentation of the proposed type of support services.
Client # 4 was admitted on December 19, 2022 and was discharged on May 1, 2023. The individual treatment and rehabilitation plan was completed on December 19, 2022; however, the plan did not include documentation of the proposed type of support services.
Client # 6 was admitted on May 9, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 9, 2023; however, the plan did not include documentation of the proposed type of support services.
This is a repeat citation from the October 14, 2022 annual licensure renewal inspection.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- The Facility Director will update the treatment plan on EHR to include the type of support services. (12/2/23)
- On 11/14/23 - The Clinical Supervisor and Clinical Director will conduct a treatment plan training based on the DDAP standards during group and to make sure all staff are documenting the type of support rehabilitation services.
- In the meantime, staff will be trained and educated in how to include the type of support services needed on the treatment plans moving forward.
- The Clinical Supervisor and/or Clinical Director will also provide and document individual supervision as well as view treatment plans during the session to verify compliance.
- The Compliance Director will audit at least 10% of new admissions and current clients to ensure treatment plans document the type and frequency of services.
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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 client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of four applicable records reviewed.
Client # 2 was admitted on October 19, 2022 and was discharged on September 26, 2023. The individual treatment and rehabilitation plan was completed on November 2, 2022 and a treatment plan update was due to be completed by January 2, 2023; however, no treatment plan update was completed prior to the client ' s discharge.
Client # 4 was admitted on December 19, 2022 and was discharged on May 1, 2023. The individual treatment and rehabilitation plan was completed on December 19, 2022 and a treatment plan update was due to be completed by February 19, 2023; however, no treatment plan updates were completed prior to the client ' s discharge.
Client # 5 was admitted on March 22, 2023 and was active at the time of the inspection. A treatment plan update was completed on July 6, 2023 and the next treatment plan update was due to be completed by September 6, 2023, however, no additional treatment plan updates were completed prior to the inspection.
Client # 6 was admitted on May 9, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 9, 2023 and a treatment plan update was due to be completed by July 9, 2023; however, no treatment plan updates were completed prior to the inspection.
This is a repeat citation from the October 14, 2022 and December 1, 2021 annual licensure renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The Clinical Director and the Clinical Supervisor have implemented a tracking spread sheet to monitor all treatment plan reviews and updates required at least every 60 days.
- The tracking tool and results will be discussed at the group and individual clinical supervision meetings
- Each staff member will be responsible tracking and updating his/her case load for documentation dates and due dates, including treatment plans.
- The Clinical Director and the Clinical Supervisor will review upcoming treatment plans during each individual supervision with staff to stay current with documentation due dates.
- The Clinical Director and the Clinical Supervisor will inform staff that for any potential lapse in treatment plans that she will be notified immediately, and a case management note is documented to reflect gap and next steps.
- The Compliance Director will monitor 10% of the client's treatment plans monthly to ensure that this standard is being met.
- Client #5 was contacted via phone and email by Facility Director with regard to non-compliance in participation in treatment. A warning letter is being mailed. Will proceed to discharge after two weeks of receiving correspondence.
- Client #6 has an upcoming scheduled appointment on 11/16/23, a treatment plan update will be completed and signed at that session.
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709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records and the facility ' s policy and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information within seven days of admission, in four of seven records reviewed.
Client # 2 was admitted on October 19, 2022 and was discharged on September 26, 2023. There was no documentation of case consultation information in the record.
Client # 3 was admitted on January 9, 2023 and was discharged on March 21, 2023. There was no documentation of case consultation information in the record.
Client # 5 was admitted on March 22, 2023 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
Client # 6 was admitted on May 9, 2023 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
This is a repeat citation from the October 14, 2022 annual licensure renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The Facility Director will work with the Compliance Director to review and update the facility's policy and procedure manual to reflect the appropriate timing for case consultation notes for admissions and readmissions.
- The updated policy will reflect the case consultations being moved from 7 days to 30 days for admissions and 60 days for readmissions.
- The Clinical Director and the Clinical Supervisor will develop and implement an admission tracking to ensure all new or re-admitted clients are receiving case consultations within the specified period identified in the revised policy and procedures manual.
- The Facility Director will monitor this tracking sheet along with the case consultation documentation to ensure this standard is being met.
- On 11/14/23, client #5 will be discussed at the group clinical supervision meeting and a case consultation will be documented.
- On 11/14/23, client #6 will be discussed at the group clinical supervision meeting and a case consultation will be documented.
- The Clinical Director will keep the case consultation documentation.
- The Clinical Supervisor will audit new admissions and re-admit admissions on a monthly basis. This data will be tracked to measure conformance.
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709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in two of two applicable records reviewed.
Client # 1 was admitted on December 15, 2022 and was discharged on January 25, 2023. The client record did not contain documentation of a completed aftercare plan.
Client # 4 was admitted on December 19, 2022 and was discharged on May 1, 2023. The client record did not contain documentation of a completed aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The Clinical Director has communicated and implemented to all clinical staff the requirement of documenting a joint after-care plan that includes the client's involvement for all successful discharges.
- The EHR has an after-care document that staff will begin to use for compliance.
- The Clinical Director will monitor and document all successful discharges to confirm after-care plans are being carried out with the client's involvement.
- Client #1 was called by Clinical Director on 11/2/23 to do an after-care plan. This was documented in a case management note.
- Client #4 was called on 11/2/2023 and an aftercare plan was completed.
- The Clinical Director will monitor and document all after care plans for discharged clients.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within 30 days of discharge, in three of three applicable records reviewed.
Client # 1 was admitted on December 15, 2022 and was discharged on January 25, 2023. Follow-up information was not documented until March 2, 2023.
Client # 3 was admitted on January 9, 2023 and was discharged on March 21, 2023. Follow-up information was not documented until April 26, 2023.
Client # 4 was admitted on December 19, 2022 and was discharged on May 1, 2023. Follow-up information was not documented until July 24, 2023.
This is a repeat citation from the October 14, 2022 and December 1, 2021 annual licensure renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The Clinical Director has communicated and implemented for all clinical staff with client's involvement to conduct and document within 30 days a follow-up engagement for all clients being discharged per policy.
- The joint follow-up information will be documented in a case management note in EMR.
- The Clinical Director will monitor at least all discharges on a monthly basis to ensure joint follow-ups are carried out.
- The Clinical Supervisor reached out to client #1 on 10/20/23 for follow up. Case management note entered to reflect outreach.
- The Clinical Supervisor reached out to client #3 on 10/19/23 for follow up. Case management note entered to reflect outreach.
- The Clinical Supervisor reached out to client #4 on 10/18/23 for follow up. Case management note entered to reflect outreach.
- The Compliance Director will audit at least 20% of all discharges to verify the requirement of within 30 days to have a follow up.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records and administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the October 14, 2022, and December 1, 2021, annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the October 6, 2023, licensing inspection.
A plan of correction for including follow-up information in the client record was submitted and approved by the Department for the October 14, 2022, and December 1, 2021, annual licensing inspections. Completing follow-up information was again found to be a deficiency in the October 6, 2023, licensing inspection.
A plan of correction for updating treatment plans within the regulatory timeframe was submitted and approved by the Department for October 14, 2022, and December 1, 2021, annual licensing inspections. Updating treatment plans was again found to be a deficiency in the October 6, 2023, licensing inspection.
A plan of correction for including proposed support services in the individual treatment and rehabilitation plan was submitted and approved by the Department for October 14, 2022, annual licensing inspection. Including support services was again found to be a deficiency in the October 6, 2023, licensing inspection.
A plan of correction for including case consultation notes in a complete client record was submitted and approved by the Department for October 14, 2022, annual licensing inspection. Case consultation notes were again found to be a deficiency in the October 6, 2023, licensing inspection.
A plan of correction for ensuring release of information forms were signed by clients was submitted and approved by the Department for October 14, 2022, annual licensing inspection. Obtaining a client signature on consent to release information forms was again found to be a deficiency in the October 6, 2023, licensing inspection.
A plan of correction for obtaining a financial audit was submitted and approved by the Department for October 14, 2022, annual licensing inspection. Obtaining an audit was again found to be a deficiency in the October 6, 2023, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
-The Clinical Director will be responsible to ensure plans of corrections are implemented as designed and approved.
-The Clinical Supervisor, Facility Director, and Compliance Director will assist in completing record audits and staff supervision for POCs related to client records.
-Additionally, the Project Director will ensure the GM and CEO complete the financial audit. |