INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 10, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Familylinks, Inc 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) 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
The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven records.
Client # 2 had a release of information for the third-party payor that had expired on June 26, 2020. There was no documentation of a valid release for the third-party payor as of September 10, 2020. The facility continued to submit documentation to the third-party payor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager will review findings with AOD clinical Staff on 10/13/2020 @ 9am. During the meeting, 28 PA code 70928 Confidentiality & Department of Drug & Alcohol Program Confidentiality Guidelines for information sharing in accordance with PA Code 255.5 will be reviewed and signed off by staff of understanding and implementing corrections. Process of Release of Information reviewed with AOD staff. Program manager will review each ROI prior to placing in EHR. Program Manager will review all letters written for ROI as well as assuring information being released is within accordance of PA Code 255.5. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in five of seven client records.
Client # 2 was to receive four individual counseling sessions per month according to the treatment plan updates dated July 3 and September 3, 2020. Client received only 1 counseling session in July 2020.
Client # 4 was to receive one individual counseling session per week according to the treatment plan dated July 25, 2019. The client received only one session in August 2019. Client was to receive two individual counseling sessions per week according to the treatment plan updates dated September 25 and November 25, 2019. Client received one session in September, November and December 2019. Client received one session in January 2020. Client was discharged on January 15, 2020.
Client # 5 was to receive one individual counseling session per week according to the treatment plan dated January 6, 2020. Client received only one session in February, March and April 2020. Client was discharged on May 20, 2020.
Client # 6 was to receive one individual counseling session per week according to the treatment plan dated February 24, 2020 and an update dated April 20, 2020. Client received one session in March and May 2020. Client received two session in April 2020 and 0 sessions in May and June 2020. Client was discharged on July 9, 2020.
Client # 7 was to receive four individual counseling sessions per month according to the treatment plan updates dated May 6 and July 7, 2020. Client received only 1 counseling session in July 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager will meet with drug and alcohol therapists on 10/13/2020 @ 9am to review results from licensing audit. Therapists will be provided with a copy of regulation 709.52 Treatment and rehabilitation services. Therapists and Program manager will review regulation regarding frequency of sessions outlined in treatment plans and ensure that frequency of sessions is being met and clear and appropriate documentation is enter into EHR system. Therapists will sign off on review of regulation 709.52 Treatment and rehabilitation services.
Effective immediately Program Manager will review each treatment plan/treatment plan update to ensure that frequency of treatment is being implemented as documented an accurately entered in the EHR.
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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
The facility failed to document follow up information in four of four client records.
Per agency policy, follow up is to be completed within seven days of discharge. Client records # 4, 5, 6 and 7 did not document follow up information within 7 days of discharge.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Manager will review regulation 709.93 Client Records with drug and alcohol therapist on 10/13/2020 @ 9am. Therapists will sign off on review of regulation and be given a copy.
Alerts have been built into the EHR to prompt therapists to complete aftercare follow ups at 7 days, 30 days and 60 days after discharge. Program Manager will provide therapists with aftercare follow up dates and review each aftercare follow up in EHR.
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