INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18-20, 2019 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, Northeast Family Healthcare 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
During a licensing inspection conducted on June 18-20, 2019, the facility failed to provide documentation of a termination letter provided to the patient for an involuntary discharge.
Patient # 5 was admitted on July 27, 2017 and administratively discharged on April 1, 2019. There was no documentation in the patients record that a termination letter was offered to the patient and the patient made aware of their right to appeal.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed the citation. On 7/17/2019 the Clinical Supervisor conducted a staff training on DDAP regulation (709.33) and PTC policy and procedure pertaining to notifying patients of a decision of involuntary termination from the treatment program. Staff will complete the EHR Administrative Withdrawal Notification for Non-Compliance form to inform patients of the reason for termination. If a patient is unavailable to sign the form due to an abrupt discharge, a form will be mailed to the patient address on file and noted in patient chart and scanned in stored documents. The Executive Director and Clinical Supervisor will utilize record reviews to monitor and ensure compliance. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
During a licensing inspection conducted on June 18-20, 2019, the facility failed to provide documentation of patients ' follow-up information in three of three patient records reviewed.
Patient # 5 was admitted on September 27, 2017 and was discharged on April 1, 2019. There was no documentation that a follow-up regarding the patient was in the patient record.
Patient # 6 was admitted on January 8, 2018 and was discharged on March 15, 2019. There was no documentation that a follow-up regarding the patient was in the patient record.
Patient # 7 was admitted on February 23, 2017 and was discharged on April 17, 2019. There was no documentation that a follow-up regarding the patient was in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed the citation. On 7/17/2019 the Clinical Supervisor conducted a staff training on DDAP regulation (715.23) and PTC policy and procedure pertaining to documentation of patient follow-up in the EHR. Clinical staff will conduct follow-up calls after discharge as indicated and complete survey questions in the EHR as applicable. Additional follow-up calls and will occur at three (3) and six (6) months after discharge. The Executive Director and Clinical Supervisor will utilize record reviews to monitor and ensure compliance. |
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
During a licensing inspection conducted on June 18-20, 2019, the facility failed to provide documentation of type and frequency of rehabilitation services in three of seven records reviewed.
Patient # 1 was admitted on June 26, 2017 and was still an active patient at the time of the inspection. The comprehensive treatment plan was not specific to the type of sessions (Individual, group, family...) or frequency of sessions (1 time, 2 times, per week...).
Patient # 3 was admitted on January 7, 2019 and was still an active patient at the time of the inspection. The comprehensive treatment plan updates were not specific to the type of sessions (Individual, group, family...) or frequency of sessions (1 time, 2 times, per week...).
Patient # 4 was admitted on October 17, 2016 and was still an active patient at the time of the inspection. The comprehensive treatment plan updates were not specific to the type of sessions (Individual, group, family...) or frequency of sessions (1 time, 2 times, per week...).
Patient # 5 was admitted on September 27, 2017 and was discharged on April 1, 2019. The comprehensive treatment plan and updates were not specific to the type of sessions (Individual, group, family...) or frequency of sessions (1 time, 2 times, per week...).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed the citation. On 7/17/2019 the Clinical Supervisor conducted a staff training on DDAP regulation (709.92) and PTC policy and procedure pertaining to documentation of the type and frequency of rehabilitation services in the EHR. The training will be specific to identifying and documenting the type of sessions (individual, group, etc) and the frequency of the sessions (the number of times per week/month)in the patient EHR. The Executive Director and Clinical Supervisor will utilize weekly record reviews to monitor and ensure compliance.
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