INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 2, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Montco Recovery Center 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in one of four applicable personnel records reviewed.Employee # 5 was hired as a counselor on January 1, 2022. The training in the use of the fire extinguisher was not completed upon employment as it was completed on February 17, 2022. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
It is the current practice of the facility that all new hires have the fire extinguisher training within the first 7 days of hire, however our policy states that we will have it done within the first 30 days. In March, we hired an Administrative Assistant who's responsible for all HR charts and will ensure this is completed in a timely manner. The Clinical Director will oversee that each HR chart has met all of the timeline documentations as a double check. |
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 the specific information to be disclosed on consent to release information forms in one of fourteen client records reviewed. Client # 10 was admitted to the outpatient activity on May 23, 2022 and was still active at the time of the inspection. The release of information form to the funding source was signed and dated by the client and witness on May 25, 2022, but the release form did not include the specific information to be disclosed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Patient Financial Responsibility Release of Information and Assignment Agreement Form has been modified to ensure that the specific information to be disclosed has been added and will be checked off prior to the client signing.
The Administrative Assistant will ensure that all appropriate boxes have been checked.
The Clinical Director will double check that the release form has been completed in its entirety.
Update:
The client re-signed the release of information form to the funding source on 8/16/22 @ 7:23pm. The witness also signed this document 8/16/22 @ 7:23pm |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the witness on release of information forms in two of fourteen client records reviewed, Additionally, the facility failed to document the dated signature of the witness at the same time as the client on release of information forms in two of fourteen client records reviewed. Client # 4 was admitted to the partial hospitalization activity on March 7, 2022 and was discharged on March 28, 2022. The release of information forms to an emergency contact, a funding source, and a lawyer were signed by the client on March 8, 2022; however, all the release forms were signed by the witness on March 10, 2022.Client # 5 was admitted to the partial hospitalization activity on April 25, 2022 and was discharged on May 15, 2022. The release of information form to the funding source was signed and dated by the client on April 22, 2022; however, the release form did not include the dated signature of the witness.Client # 8 was admitted to the outpatient activity on March 29, 2022 and was still active at the time of the inspection. The release of information forms to an emergency contact, a funding source, and a lawyer were signed by the client on March 8, 2022; however, all the release forms were signed by the witness on March 10, 2022.Client # 9 was admitted to the outpatient activity on May 16, 2022 and was still active at the time of the inspection. The release of information form to the funding source was signed and dated by the client on April 22, 2022; however, the release form did not include the dated signature of the witness.This is a repeat citation from the August 31, 2021 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The release of the information has been modified to require that the witness must sign before proceeding to the next form.
The Administrative Assistant will review that all forms are completed at the conclusion of the assessment.
The Clinical Director will review and sign off on all forms to ensure appropriate completion.
Update:
The ROIs for client #4 and #8 were corrected and re-signed 8/18/22 @ 12pm.
The ROIs for client #5 and #9 were corrected and re-signed 8/18/22 @ 7:30pm. |
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 document the date, event, or condition upon which the consent will expire on consent to release information forms in twelve of twelve applicable client records reviewed. In each applicable record reviewed, the release of information form to the funding source did not include the date, event, or condition upon which the consent would expire.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Patient Financial Responsibility Release of Information and Assignment Agreement Form has been modified to ensure that the date, event, or condition upon which the consent would expire has been added to the form.
The Administrative Assistant will ensure that the release form has been completed in its entirety.
The Clinical Director will double check that the release form has been completed in its entirety. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the client's individual treatment and rehabilitation plan in seven of seven applicable client records reviewed.In each partial hospitalization client record reviewed, the individual treatment and rehabilitation plan failed to include documentation of the type of treatment and rehabilitation services provided to the client.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Golden Thread Treatment Plan was modified to include the type of treatment that the Plan would be addressed and implemented in. The type will include options for individual, group and family therapy.
The Primary Therapist will ensure that all appropriate boxes have been checked.
The Clinical Director will double check that the treatment plan has been completed in its entirety.
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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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the client's individual treatment and rehabilitation plan in seven of seven applicable client records reviewed.In each outpatient client record reviewed, the individual treatment and rehabilitation plan failed to include documentation of the type of treatment and rehabilitation services provided to the client.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Golden Thread Treatment Plan was modified to include the type of treatment that the Plan would be addressed and implemented in. The type will include options for individual, group and family therapy. This treatment plan will cover any client regardless of level of care.
The Primary Therapist will ensure that all appropriate boxes have been checked.
The Clinical Director will double check that the treatment plan has been completed in its entirety. |