INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 23, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Fellowship House 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of CPR the facility failed to ensure that at adequate CPR coverage during operating hours as only one staff member is CPR certified.
These findings were discussed with Facility staff during the inspection process.
|
Plan of Correction
Project Director was able to identify three staff members with proper CPR training. Between these three staff members, they cover all hours of operation.
In addition this, Project Director has enrolled four other staff members in CPR training (per the Red Cross).
The facility has taken the following steps to ensure this deficiency does not recur:
- The facility has altered its policies and procedures to state that "one staff member who is CPR certified must be on staff during all operational hours"
- The facility has implemented a daily/weekly/monthly schedule that includes that at least one staff member who is CPR certified is on staff during all operational hours.
- The facility has implemented a policy whereby the Facility Director and Project Director will audit the schedule bi-annually to ensure this deficiency does not occur again. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on a review of the facility ' s policy and procedure manual and facility staff, the facility failed to document if project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In order to correct the deficiency, our Project Director has prepared, updated and signed a written manual delineating project policies and procedures. This has been documented in our records. Project Director will update this manual annually.
A specific clause has been added to our Policies & Procedures detailing this.
The facility has taken the following steps to ensure this deficiency does not recur:
- The facility has altered its policies and procedures to state that "the facility shall document when the project directors prepares, annually updates and signs a written manual delineating project policies and procedures."
- The facility has implemented a policy whereby the Facility Director and Project Director will audit the project policies and procedures manual and document this audit to ensure this deficiency does not occur 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.
|
Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in seven out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #1 was admitted on April 2, 2024 and was still active at the time of the inspection.
Client #2 was admitted on March 20, 2024 and was still active at the time of the inspection.
Client #3 was admitted on February 15, 2024 and was still active at the time of the inspection
Client #4 was admitted on December 5, 2023 and was still active at the time of the inspection
Client #5 was admitted on December 19, 2023 and was discharged on January 12, 2024
Client #6 was admitted on September 25, 2023 and was discharged on November 8, 2023
Client #7 was admitted on August 11, 2023 and was discharged on February 5, 2024.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Project Director and Facility Director have implemented a new policy whereby a consent to release information form is obtained from every client during intake prior to releasing information.
Project Director and Facility Director additionally ran an audit of all clients to ensure that records were updated to include a signed consent to release information. This includes the seven records reviewed.
The facility has taken the following steps to ensure this deficiency does not recur:
- The facility has altered its policies and procedures to state that "clients will complete and sign a consent to release information form prior to releasing information."
- The facility has implemented a policy whereby the Facility Director and Project Director will audit client records and consents to release information to ensure this deficiency does not occur again. |
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.
|
Observations
Based on the review of seven client records, the facility failed to document a completed consent to release information form in one out of seven records reviewed.
Client #1 was admitted on April 2, 2024 and was still active at the time of the inspection.
Consent forms that were dated April 2, 2024 to another treatment facility and the emergency contact failed to include the purpose of the release.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Project Director and Facility Director have implemented a new policy whereby a consent to release information form is obtained from every client during intake prior to releasing information.
Project Director and Facility Director additionally ran an audit of all clients to ensure that records were updated to include a signed consent to release information. This includes Client #1 mentioned here.
The facility has taken the following steps to ensure this deficiency does not recur:
- The facility has altered its policies and procedures to state that "clients will complete and sign a consent to release information form prior to releasing information."
- The facility has implemented a policy whereby the Facility Director and Project Director will audit client records and consents to release information monthly to ensure this deficiency does not occur again. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
Based on a review of seven client records, the facility failed to include documentation of all required client rights including, clients receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment in all seven client records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Project Director and Facility Director have implemented a policy whereby
documentation of all required client rights is presented to client upon intake, after which the client signs this documentation. This documentation includes clients receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment in all seven client records reviewed.
Project Director and Facility Director additionally ran an audit of all clients to ensure that records were updated to include signed documentation of client rights.
The facility has taken the following steps to ensure this deficiency does not recur:
- The facility has altered its policies and procedures to state that "all clients must receive and sign a clients rights document detailing client rights including, clients receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment in all seven client records reviewed. "
- The facility has implemented a policy whereby the Facility Director and Project Director will audit client records and rights forms to ensure this deficiency does not occur again.
The Fellowship House Compliance/HR team will ensure these corrective actions are implemented. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of seven client records, the facility failed to include documentation of all the required client rights, including the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in seven out of seven records.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director and Facility Director have implemented a policy whereby
documentation of all required client rights is presented to client upon intake, after which the client signs this documentation. This documentation includes that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in seven out of seven records.
Project Director and Facility Director additionally ran an audit of all clients to ensure that records were updated to include signed documentation of client rights.
The facility has taken the following steps to ensure this deficiency does not recur:
- The facility has altered its policies and procedures to state that "all clients must receive and sign a clients rights document detailing client rights including the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion."
- The facility has implemented a policy whereby the Facility Director and Project Director will audit client records and rights forms to ensure this deficiency does not occur again.
The Fellowship House Compliance/HR team will ensure these corrective actions are implemented. |
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.
|
Observations
Based on a review of seven client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not identify that 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 in seven out of seven records.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director and Facility Director have implemented a policy whereby
documentation of all required client rights is presented to client upon intake via clients right form, after which the client signs this documentation. This documentation identifies that 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.
Project Director and Facility Director additionally ran an audit of all clients to ensure that records were updated to include signed documentation of client rights.
The facility has taken the following steps to ensure this deficiency does not recur:
- The facility has altered its policies and procedures to state that "all clients must receive and sign a clients rights document identifying that 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."
- The facility has implemented a policy whereby the Facility Director and Project Director will audit client records and rights forms to ensure this deficiency does not occur again.
The Fellowship House Compliance/HR team will ensure these corrective actions are implemented. |
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.
|
Observations
Based on a review of seven client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not identify that clients have the right to appeal a decision limiting access to their records to the director in seven out of seven records.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director and Facility Director have implemented a policy whereby
documentation of all required client rights is presented to client upon intake via a client's right form, after which the client signs this documentation. This documentation identifies that clients have the right to appeal a decision limiting access to their records to the director.
Project Director and Facility Director additionally ran an audit of all clients to ensure that records were updated to include signed documentation of client rights.
The facility has taken the following steps to ensure this deficiency does not recur:
- The facility has altered its policies and procedures to state that "all clients must receive and sign a clients rights document identifying that clients have the right to appeal a decision limiting access to their records to the director."
- The facility has implemented a policy whereby the Facility Director and Project Director will audit client records and rights forms to ensure this deficiency does not occur again.
The Fellowship House Compliance/HR team will ensure these corrective actions are implemented.
|
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.
|
Observations
Based on a review of seven client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not identify that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in seven out of seven records.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director and Facility Director have implemented a policy whereby
documentation of all required client rights is presented to client upon intake via a client's right form, after which the client signs this documentation. This documentation identifies that clients have the right to appeal a decision limiting access to their records to the director.
Project Director and Facility Director additionally ran an audit of all clients to ensure that records were updated to include signed documentation of client rights.
The facility has taken the following steps to ensure this deficiency does not recur:
- The facility has altered its policies and procedures to state that "all clients must receive and sign a clients rights document identifying that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records."
- The facility has implemented a policy whereby the Facility Director and Project Director will audit client records and rights forms to ensure this deficiency does not occur again.
The Fellowship House Compliance/HR team will ensure these corrective actions are implemented. |
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.
|
Observations
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not identify that clients have the right to submit rebuttal data or memoranda to their own records in seven out of seven records.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director and Facility Director have implemented a policy whereby
documentation of all required client rights is presented to client upon intake via a client's right form, after which the client signs this documentation. This documentation identifies that clients have the right to submit rebuttal data or memoranda to their own records.
Project Director and Facility Director additionally ran an audit of all clients to ensure that records were updated to include signed documentation of client rights.
The facility has taken the following steps to ensure this deficiency does not recur:
- The facility has altered its policies and procedures to state that "all clients must receive and sign a clients rights document identifying that clients have the right to submit rebuttal data or memoranda to their own records."
- The facility has implemented a policy whereby the Facility Director and Project Director will audit client records and rights forms to ensure this deficiency does not occur again.
The Fellowship House Compliance/HR team will ensure these corrective actions are implemented. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of two applicable client records reviewed.
Client #4 was admitted on December 5, 2023 and was still active at the time of the inspection. A treatment plan update was completed on December 19, 2023 and the next update was due no later than February 19, 2024; however, no update was completed at the time of the inspection.
Client #7 was admitted on August 11, 2023 and was discharged on February 5, 2024.
A treatment plan was completed on August 11, 2023 and the next update was due no later than October 11, 2023; however, no update was documented in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Project Director and Facility Director have policies and procedures in place that state client treatment plans must be completed with the client within 3 days of admission. Once treatment plans are complete, counselors are to include any progress related to treatment plans in their individual and group note documentation. Treatment plans must also be updated and reviewed with the client no less than once every thirty days.
Treatment plan policies and procedures were reviewed with all clinical staff to ensure understanding of this policy and its implementation.
Project Director and Facility Director additionally ran an audit of all clients to ensure that all current treatment plans have been updated correctly.
The facility has taken the following steps to ensure this deficiency does not recur:
- The facility has altered its policies and procedures to state that "all treatment plan updates must occur within the DDAP regulatory timeframe"
- The facility has implemented a policy whereby the Facility Director and Project Director will audit client treatment plans monthly to ensure this deficiency does not occur again.
The Fellowship House Compliance/HR team will ensure these corrective actions are implemented. |
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.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include aftercare information in one out of one applicable discharged records reviewed.
Client #7 was admitted on August 11, 2023 and was discharged on February 5, 2024.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director and Facility Director have policies and procedures in place that state client records must be complete and include detailed aftercare information which is entered just prior to discharge.
Discharge and aftercare policies and procedures were reviewed with all clinical staff to ensure understanding of this policy and its implementation.
Project Director and Facility Director additionally ran an audit of all clients to ensure that all current discharge summaries and aftercare plans have been updated correctly.
The facility has taken the following steps to ensure this deficiency does not recur:
- The facility has altered its policies and procedures to state that "all clients will be provided a complete client record, which is to include aftercare information in discharge records."
- The facility has implemented a policy whereby the Facility Director and Project Director will audit client records, discharge records and aftercare plans monthly to ensure this deficiency does not occur again.
The Fellowship House Compliance/HR team will ensure these corrective actions are implemented. |
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in three out of three applicable client records reviewed.
Client #5 was admitted on December 19, 2023 and was discharged on January 12, 2024
Client #6 was admitted on September 25, 2023 and was discharged on November 8, 2023
Client #7 was admitted on August 11, 2023 and was discharged on February 5, 2024.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director and Facility Director have policies and procedures in place that state client records must be complete and include full discharge summaries.
Discharge summary and aftercare policies and procedures were reviewed with all clinical staff to ensure understanding of this policy and its implementation.
Project Director and Facility Director additionally ran an audit of all clients to ensure that all current discharge summaries and aftercare plans have been updated correctly.
The facility has taken the following steps to ensure this deficiency does not recur:
- The facility has altered its policies and procedures to state that "all clients will be provided a complete client record, which is to include a discharge summary."
- The facility has implemented a policy whereby the Facility Director and Project Director will audit client records, discharge records and aftercare plans monthly to ensure this deficiency does not occur again. |
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.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of three discharged records reviewed.
Client #5 was admitted on December 19, 2023 and was discharged on January 12, 2024
Client #6 was admitted on September 25, 2023 and was discharged on November 8, 2023
Client #7 was admitted on August 11, 2023 and was discharged on February 5, 2024.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director and Facility Director have policies and procedures in place that state client records must be complete and include client follow-up information and status.
Client follow-up procedures were reviewed with all clinical staff to ensure understanding of this policy and its implementation.
Project Director and Facility Director additionally ran an audit of all clients to ensure that all follow-up information has been updated correctly.
The facility has taken the following steps to ensure this deficiency does not recur:
- The facility has altered its policies and procedures to state that "all clients will be provided a complete client record, which is to include follow-up information in discharge records."
- The facility has implemented a policy whereby the Facility Director and Project Director will audit client records, discharge records and aftercare plans monthly to ensure this deficiency does not occur again. |