INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 22-23, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Dreamlife Recovery LLC. was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this investigation.
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Plan of Correction
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704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of the primary care staff hours, conducted on February 4, 2020, the facility failed to provide one primary care staff for every seven patients in the detoxification activity.
A schedule was submitted that indicated the hours worked for the detox staff for the period from December 10, 2019 through January 24, 2020. The facility was not in compliance during the following time-frames:
December 13, 2019: census 8; 1 primary care staff from 12 am to 7 am.
December 23, 2019: census 8; 1 primary care staff from 11 pm to 7 am.
January 6, 2020: census 8; 1 primary care staff from 12 am to 7 am & 11 pm to 12 am.
January 7, 2020: census 8; 1 primary care staff from 12 am to 7 am & 11 pm to 12 am.
January 8, 2020: census 10; 1 primary care staff from 12 am to 7 am & 11 pm to 12 am.
January 9, 2020: census 11; 1 primary care staff from 12 am to 7 am & 11 pm to 12 am.
January 10, 2020: census 11; 1 primary care staff from 12 am to 7 am & 11 pm to 12 am.
January 11, 2020: census 10; 1 primary care staff from 12 am to 7 am & 11 pm to 12 am.
January 12, 2020: census 14; 1 primary care staff from 12 am to 7 am & 11 pm to 12 am.
January 13, 2020: census 16; 2 primary care staff from 12 am to 7 am & 6 pm to 12 am.
January 14, 2020: census 17; 2 primary care staff from 12 am to 7 am & 6 pm to 12 am.
January 15, 2020: census 15; 2 primary care staff from 12 am to 7 am & 6 pm to 12 am.
January 16, 2020: census 15; 2 primary care staff from 12 am to 7 am & 6 pm to 12 am.
January 18, 2020: census 8; 1 primary care staff from 11 pm to 12 am.
January 19, 2020: census 9; 1 primary care staff from 12 am to 7 am & 11 pm to 12 am.
January 20, 2020: census 10; 1 primary care staff from 12 am to 7 am & 11 pm to 12 am.
January 21, 2020: census 8; 1 primary care staff from 12 am to 7 am & 11 pm to 12 am.
January 22, 2020: census 9; 1 primary care staff from 12 am to 7 am & 11 pm to 12 am.
January 23, 2020: census 9; 1 primary care staff from 12 am to 7 am & 11 pm to 12 am.
January 24, 2020: census 9; 1 primary care staff from 12 am to 7 am & 11 pm to 12 am.
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Plan of Correction
On 2/17/20 The Vice President of Operations met with the leadership team members responsible for developing the detoxification schedule to discuss the departments recent clarification of a primary care staff member. As a result of this meeting, as of 2.24.20 the facility staffing in the detox will be in compliance with the regulations set forth in 704.12(1)(i), regarding primary care staff in this activity. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Five client records were reviewed on January 22-23, 2020; The facility failed to adhere to procedures for treatment and rehabilitation management in the detoxification level of care in three of five client records reviewed.
The Nursing Treatment Plan in the detoxification activity stipulated " Q 4-hour checks for the first 24 hours " , however the following information was documented in the client records reviewed:
Client #1 was admitted on 1/9/2020 and was an active client at the time of the investigation. The nursing treatment plan was dated 1/9/2020; according to the medical record checks were performed at 8:38 pm on 1/8/2020 but not again until 7:00 am on 1/10/2020.
Client #2 was admitted on 12/28/2019 and was an active client at the time of the investigation. The nursing treatment plan was dated 12/28/2019; according to the medical record checks were performed at 3:28 pm on 12/28/2019 but not again until 6:59 am on 12/29/2019.
Client #3 was admitted on 1/1/2020 and was an active client at the time of the investigation. The nursing treatment plan was dated 1/1/2020; according to the medical record checks were performed at 7:20 pm on 1/1/2020 but not again until 6:46 am on 1/2/2020.
Facility staff acknowledged that the procedure was not followed in these cases.
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Plan of Correction
The Vice President of Operations and the Quality Assurance Coordinator met to discuss why the team failed to adhere to the Nursing Treatment Plans. It was identified that a formal written policy and procedure was not developed and an official training on the development and implementation of a Nursing Treatment plan had not previously occurred with the nursing staff. As a result, Policy Number CL-8.018 Nursing Treatment Plan has been written. On 2/20/20 the Director of Nursing trained the nursing team on the policy to ensure that the nurses are knowledgeable of the treatment planning expectations and are aware that all goals and objectives are maintained, specifically Q 4-hour vital sign checks for the first 24 hours for Detoxification clients.
In addition to the policy development and training, the overnight nursing staff are conducting 24-hr chart checks and "checking for vital signs being completed according to the treatment plan " has been added as a standing item to be checked every 24 hours. If an area of non-compliance is identified, a corrective action plan is to be submitted to the Vice President of Operations by the Director of Nursing.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to document valid policy and procedures for the security and release of client records.
The document labeled - " DreamLife Recovery LLC Client Rights " Stipulates:
" The confidentiality of alcohol and drug abuse client records maintained by the program is protected by Federal law and regulations. Generally, the program may not say to a person outside the program that (a) client attends the program or disclose and information identifying a client as an alcohol or drug abuser unless:
1.The client consents in writing
2.The disclosure is allowed by a court order; or
3.The disclosure is made to medical personnel
4.The disclosure to a qualified person for research, audit or program evaluation; or
5.The disclosure is made to protect self or others or a crime has been committed; or
6.The disclosure in the event of threats of harm to self or others (Duty to Warn). "
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Plan of Correction
The facility has removed the cited verbiage on the Dreamlife Recovery, LLC Client Rights form that is not in compliance with 4 PA Code 255.5. In addition, the PHI logs of each client were reviewed to ensure that there was no information released that would be in violation of 4 PA Code 255.5 and 42 CFR Part 2.
In an effort to ensure ongoing compliance, Policy Number CL-1:008, Client Confidentiality and HR -2.010 Employee Confidentiality policy were redistributed to the staff along with a copy of 4 PA Code 255.5 and 42 CFR part 2. Both of the referenced policies state that all staff will be trained on 4 PA Code 255.5 and 42 CFR Part 2 on the first day of work and then annually. To re-educate staff, the facility held an all staff training on the limitations of release of information within 4 PA Code 255.5 and 42 CFR Part 2 and discussed the revised Dreamlife Recovery, LLC Client Rights form on 2/20/20.
In addition, each month the QA Coordinator and Executive Director randomly audit 30% of all active charts for appropriate completion of confidentiality releases. Auditing of Client Rights form to ensure that the old forms have not reappeared has been added as a standing item to the confidentiality audit. If an instance of non-compliance is identified, a corrective action plan is required to be submitted to the Performance Improvement Committee with the audit report.
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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
Five client records were reviewed on January 22-23, 2020; The facility failed to document a valid consent to release information form to the funding source in five of five client records reviewed.
-Client #1 was admitted on 1/9/2020 and was an active client at the time of the investigation.
-Client #2 was admitted on 12/28/2019 and was an active client at the time of the investigation.
-Client #3 was admitted on 1/1/2020 and was an active client at the time of the investigation.
-Client #4 was admitted on 4/15/19 and discharged on 5/8/19.
-Client #5 was admitted on 1/8/2020 and was an active client at the time of the investigation.
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Plan of Correction
The Executive Director held a staff training on 02/04/2020 instructing the staff on how to properly complete ROI's which includes completing an ROI for each funding source. This training was provided by the Executive Director, to the case management, behavioral health technician and clinician departments responsible for completing Release of Information forms.
To ensure ongoing compliance, auditing of ROI's has been added as a standing agenda item to the monthly Performance Improvement Committee agenda where the Executive Director and Quality Assurance Coordinator will review a random sampling of completed ROI's to verify that the staff are completing these forms properly. Outcomes of the monthly audit will be submitted to the Performance Improvement Committee, where at least 30% of open charts will be reviewed. If an instance of non-compliance is identified, a corrective action plan is required to be submitted to the Performance Improvement Committee.
For all active charts identified at the time of the investigation that did not have a release of information signed for the funding source, an ROI for the funding source was completed on 2/4/20. |
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
Five client records were reviewed on January 22-23, 2020; The facility failed to document a valid purpose for the information to be released in one of five client records reviewed.
Client #4 was admitted on 4/15/19 and discharged on 5/8/19. A consent to release information to a family member stated the purpose for the release was ' Court Services ' .
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Plan of Correction
The Executive Director held a staff training on 02/04/2020 instructing the staff on how to properly complete ROI's which includes documenting a valid purpose for the information to be released. This training was provided by the Executive Director, to the case management, behavioral health technician and clinician departments responsible for completing Release of Information forms.
To ensure ongoing compliance, auditing of ROI's has been added as a standing agenda item to the monthly Performance Improvement Committee agenda where the Executive Director and Quality Assurance Coordinator will review a random sampling of completed ROI's to verify that the staff are completing these forms properly. Outcomes of the monthly audit will be submitted to the Performance Improvement Committee, where at least 30% of open charts will be reviewed. If an instance of non-compliance is identified, a corrective action plan is required to be submitted to the Performance Improvement Committee.
For the specific record identified, the PHI log was reviewed to ensure that no information was released in violation of 4 PA Code 255.5 and 42 CFR Part 2. Upon clinical chart review of Client #4 the discrepancy in the ROI was noted and a note was added into the chart stating that in the event that information needs to be released to this contact again, the patient would need to be contacted and a new Release of Information would need to be signed.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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
Five client records were reviewed on January 22-23, 2020; The facility failed to document the type and frequency of treatment on the treatment plans in three of five client records reviewed.
Client #1 was admitted on 1/9/2020 and was an active client at the time of the investigation. A comprehensive treatment plan dated 1/16/2020 did not specify the type and frequency of treatment.
Client #2 was admitted on 12/28/2019 and was an active client at the time of the investigation. A comprehensive treatment plan dated 1/6/2020 did not specify the type and frequency of treatment.
Client #3 was admitted on 1/1/2020 and was an active client at the time of the investigation. A comprehensive treatment plan dated 1/3/2020 did not specify the type and frequency of treatment.
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Plan of Correction
On 3/4/2020 the Quality Assurance Coordinator and Vice President of Operations met to redesign the Clinical Treatment Plans to automatically include the frequencies of treatment for each type of service being provided.
To ensure ongoing compliance, the Vice President of Clinical Operations will review and countersign all comprehensive treatment plans, verifying compliance of 709.52 (Treatment Type and Frequency) during her review.
In addition to the counter-signature, the VP of Clinical Ops conducts a monthly chart audit where a random sampling of 30% of all active charts are auditing for overall compliance. Indication of treatment type and frequency has been added to the chart audit template as of 3.4.2020 If an instance of non-compliance is identified, a corrective action plan is required to be submitted to the Executive Director within 7 days. |