INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on may 8, 2018 at ADAPPT Outpatient Treatment Center by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, ADAPPT Outpatient Treatment Center 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted on May 8, 2018, the facility failed to ensure that the water temperature in the male bathroom did not exceed 120 degrees fahrenheit
When tested, the water temperature was 144 degrees farenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The owner of the Madison Building where the ADAPPT Outpatient is located has had Maintenance personnel correct the water temperature to be within the proper range.
ADAPPT personnel shall periodically check the temperature at the Madison to ensure compliance. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection conducted on May 8, 2018, the facility failed to ensure that fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
The fire extinguisher closest to the entrance/exit did not have a tag indicating inspection of the fire extinguisher.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Madison Building owner has confirmed that all fire extinguishers are inspected, tagged, and approved by a fire extinguisher company annually in the month of July. The next inspection is due and scheduled to take place in July 2018.
The fire extinguisher closest to the entrance/exit that is missing a tag (unfortunately torn off) will be replaced July 16, 2018.
Staff has been asked to be more diligent about reporting this issue to the Deputy Director. Once notified the Deputy Directed shall immediately notify the landlord to ensure the tag is replaced.
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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
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) where applicable for releases of information in three of seven client records reviewed.
Client records, #2, #3 and #7 had consent to release forms that were missing the witness signature, documentation that a copy of the consent was offered to the client, and/or the expiration date of the consent form. Additionally, all clients were provided a clients right template that allowed for the release of information under "exceptions of emergencies, probability of imminent danger to self or others, court orders and faced with terrorists acts upon imminent danger to ones self".
Client #2 was admitted on 04/04/18. The client record had consent to release forms that were not signed by staff and did not have an expiration date for the consent. The facility was unable to provide documentation that a copy of the consent had been offered to the client.
Client #3 was admitted on 03/13/18. The client record had consent to release forms that were not signed by staff and did not have an expiration date for the consent. The facility was unable to provide documentation that a copy of the consent had been offered to the client.
Client #7 was admitted 12/05/17. The client record had consent to release forms that were not signed by staff and did not have an expiration date for the consent. The facility was unable to provide documentation that a copy of the consent had been offered to the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor shall ensure that all client consent forms shall be within the limits of PA Code 255.5 (b).
The Clinical Supervisor shall ensure by weekly inspection of client files that
all client files shall include documentation that "consent" was offered to the client; said consent shall include an expiration date, and the client's signature.
Supervisory audits by the Facility Director shall occur monthly to ensure compliance with this correction. |
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.
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Observations
Based on a review of seven client records, the facility failed to notify clients of some of their specific rights in seven of seven records reviewed.
Seven client records reviewed contained a document labeled Confidentiality of Treatment and a template labeled Clients Rights which failed to indicate that the facility could not discriminate in the provision of services based on age, ethnicity, marital status, or sexual orientation.
This was discussed with facility staff.
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Plan of Correction
Going forward the Clinical Supervisor will ensure that a recently revised "Client Rights" form signed by the resident that includes the following" shall be included in every client file.
You have the right to competent, timely treatment delivered in a respectful manner by a treatment professional.
You have the right to have your communications with the GEO ADAPPT Outpatient Treatment Services treated in a confidential manner. You have the right to determine to whom and under what circumstances information about your treatment may be released. Confidential information may not be released without your written consent with the exception of emergencies, probability of imminent danger to self or to others, court orders and faced with terrorist acts upon imminent danger to one's self. You have the right to expect reasonable continuity of care. You have the right to ask for outside consultation, evaluation, and/or treatment.
You have the right to have questions answered about procedures at any time.
You have the right to non-discriminatory treatment without prejudice to age, race, creed, sex, ethnicity, color, national origin, marital status , sexual orientation, handicap, or religion. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of seven client records the facility failed to document a psychosocial evaluation in one of seven records reviewed.
Client #7 was admitted on 12/5/17 and had been discharged on an unknown date. There was no psychosocial evaluation in the record as of the date of the licensing inspection.
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Plan of Correction
The Clinical Supervisor, with oversight from the Facility Director, shall ensure that a comprehensive Psychological Evaluation will be completed within 7 days for every client who enters treatment at ADAPPT. |
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
Based on a review of seven outpatient client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in four of seven records reviewed.
Client #2 was admitted on 4/4/18 and was still an active client at the time of inspection. The comprehensive treatment plan, dated 4/4/18, indicated 1 individual per month and 4 group sessions per week. There was no record of service or group notes documenting tha the client received group counseling as per the treatment plan.
Client #3 was admitted on 3/13/18 and was still an active client at the time of inspection. The comprehensive treatment plan, dated 3/13/18, indicated 1 individual per month and 4 group sessions per week. There was no record of service or group notes documenting tha the client received group counseling as per the treatment plan.
Client #6 was admitted 3/6/18 and was discharged on an unknown date. The comprehensive treatment plan, dated 3/13/18, indicated 1 individual per month and 4 group sessions per week. There was no record of service or group notes documenting tha the client received group counseling as per the treatment plan.
Client #7 was admitted on 12/5/17 and was discharged on an unknown date. The comprehensive treatment plan, dated 3/13/18, indicated 1 individual per month and 4 group sessions per week. There was no record of service or group notes documenting tha the client received group counseling as per the treatment plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor shall ensure that counseling services are provided and documented according to the individual Treatment and Rehabilitation plan in the following ways: timely plan updates, case consultations, progress notes, and records of service.
Random monthly audits by a clinical administrator shall occur to ensure completion. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include progress notes, record of service, a discharge summaries, termination letter, aftercare plans, and follow-up information in client record.
Client #1 was admitted on 5/3/18 and was still an active client at the time of inspection. The client record did not contain documentation of a record of services provided.
Client #2 was admitted on 4/4/18 and was still an active client at the time of inspection. The client record did not contain documentation of a record of services provided or progress notes.
Client #3 was admitted on 3/13/18 and was no longer an active client at the time of inspection. The client record did not contain documentation of progress notes, a discharge summary, or termination letter.
Client #4 was admitted on 6/26/17 and discharged on 12/30/17. The client record did not contain documentation of a discharge summary, or follow-up.
Client #6 was admitted 3/6/18 and was no longer an active client at the time of inspection. The client record did not contain documentation of progress notes, a discharge summary, or termination letter.
Client #7 was admitted on 12/5/17 and was no longer an active client at the time of inspection. The client record did not contain documentation of progress notes, a discharge summary, or termination letter.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There shall be a complete chronological listing of the client record for every service for every individual which shall include all information related to the client's involvement with the project. This shall include, but not be limited to everything from the intake process to the after-care and follow-up plan. the record shall be found at all times within the client file and be accurate to the day. Progress notes shall be documented and filed in the client record after each contact. The Clinical Supervisor shall ensure by weekly inspection of client files that a daily and accurate record of service is being maintained.
Supervisory audits by a Clinical Administrator shall occur monthly to ensure compliance with this plan of correction. |