INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on August 21-22, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clear Choices, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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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
Based on a review of client records, the facility failed to document the person, agency or organization to whom the information would be disclosed in one of seven records. Client #2 was admitted on April 19, 2024 and was still active at the time of the inspection. A release of information was signed and dated by the client on April 19, 2024 and did not include the name of person, agency or organization to whom the information would be disclosed.These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will provide in house training to review and reinforce elements necessary to demonstrate the individual has provided voluntary consent to release information. These elements include: Name of the person or agency, Specific Information to Disclose, Purpose of Disclosure, Dated Signature, and Date or event of expiration. Training will occur with staff prior to 9/30/2024 and documentation of the training will be maintained on-site for review as needed. Ongoing compliance will be monitored through chart auditing. |
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 client records, the facility failed to document what specific information could be disclosed on consent to release forms in one of seven records.Client #2 was admitted on April 19, 2024 and was still active at the time of the inspection. Two release of information forms for government agencies were signed and dated by the client on April 19, 2024 and did not include the specific information to be disclosed.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will provide in house training to review and reinforce elements necessary to demonstrate the individual has provided voluntary consent to release information. These elements include: Name of the person or agency, Specific Information to Disclose, Purpose of Disclosure, Dated Signature, and Date or event of expiration. Training will occur with staff prior to 9/30/2024 and documentation of the training will be maintained on-site for review as needed. Ongoing compliance will be monitored through chart auditing. |
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 client records, the facility failed to document the purpose of the consent on the consent to release forms in two of seven records.Client #1 was admitted on December 4, 2023 and was discharged March 20, 2024. A release of information form for a government agency was signed and dated by the client on January 23, 2024 did not include the purpose of the disclosure.Client #2 was admitted on April 19, 2024 and was still active at the time of the inspection. A release of information form was signed and dated by the client on April 19, 2024 and did not include the purpose of disclosure.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will provide in house training to review and reinforce elements necessary to demonstrate the individual has provided voluntary consent to release information. These elements include: Name of the person or agency, Specific Information to Disclose, Purpose of Disclosure, Dated Signature, and Date or event of expiration. Training will occur with staff prior to 9/30/2024 and documentation of the training will be maintained on-site for review as needed. Ongoing compliance will be monitored through chart auditing. |
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 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the date, event or condition upon which the consent will expire in two of seven records.Client #1 was admitted on December 4, 2023 and was discharged March 20, 2024. A release of information form for a government agency was signed and dated by the client on January 23, 2024 did not include the date, event or condition upon which the consent will expire.Client #2 was admitted on April 19, 2024 and was still active at the time of the inspection. Four release of information forms were signed and dated by the client on April 19, 2024 and did not include the date, event or condition upon which the consent will expire.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will provide in house training to review and reinforce elements necessary to demonstrate the individual has provided voluntary consent to release information. These elements include: Name of the person or agency, Specific Information to Disclose, Purpose of Disclosure, Dated Signature, and Date or event of expiration. Training will occur with staff prior to 9/30/2024 and documentation of the training will be maintained on-site for review as needed. Ongoing compliance will be monitored through chart auditing. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in four of five applicable records reviewed.Patient #2 was admitted on April 19, 2024 and was still active at the time of the inspection. The patient did not receive the required psychotherapy hours for April 2024, May 2024, and July 2024. Patient #3 was admitted on May 9, 2023 and transferred to another facility on January 9, 2024. The patient did not receive the required psychotherapy hours for September 2023, November 2023, and December 2023. Patient #5 was admitted on July 19, 2023 and was still active at the time of the inspection. The patient did not receive the required psychotherapy hours for March 2024. Patient #8 was admitted on November 15, 2023 and was still active at the time of the inspection. The patient did not receive the required psychotherapy hours for January 2024, March 2024, and June 2024. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director will provide an in house training related to treatment planning with focus on documentation of developing the comprehensive individual treatment plan with the individual and ensuring documentation includes evidence that it was done in this manner. Training will occur with staff prior to 9/30/2024 and compliance will be monitored through routine chart auditing. Documentation of the training will be maintained on-site for review as needed. |
709.92(a) 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:
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Observations
Based on applicable records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client in client record one of three client records.Client #8 was admitted on November 15, 2023 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed on November 20, 2023 did not include documentation of the plan being developed with the client.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will provide an in house training related to treatment planning with focus on documentation of developing the comprehensive individual treatment plan with the individual and ensuring documentation includes evidence that it was done in this manner. Training will occur with staff prior to 9/30/2024 and compliance will be monitored through routine chart auditing. Documentation of the training will be maintained on-site for review as needed. |
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 client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in four of eight applicable records. The facility policy and procedure manual indicate a case consultation to occur at three months, six months, nine months, and twelve months after admission, then annually thereafter. Client #1 was admitted on December 4, 2023 and was discharged March 20, 2024. The three-month case consultation was due to occur no later than March 4, 2024, however this was not completed until March 13, 2024.Client #2 was admitted on April 19, 2024 and was still active at the time of the inspection. The three-month case consultation was due to occur no later than July 19, 2024, however this was not completed at the time of the inspection.Client #3 was admitted on May 9, 2023 and transferred to another facility on January 9, 2024. The six-month case consultation was due to occur no later than November 9, 2023, however this was not completed at the time of the inspection.Client #5 was admitted on July 19, 2023 and still active at the time of the inspection. The three-month case consultation was to occur no later than October 19, 2023, however this was not completed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will provide training in house regarding case consultation notes and the timing of that documentation. Training will occur with staff prior to 9/30/2024 and will be monitored for compliance through routine chart auditing. Documentation of the training will be maintained on-site for review as needed. |