INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26, 2017 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, Holcomb Associates, 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
Based on the review of client records, the facility failed to document the purpose of the disclosure on consent to release forms in 4 of 7 client records.
Client # 1 was admitted on 12/22/16 and was discharged on 5/2/17. A consent to release form was signed and dated on 1/3/17 to a family friend, but it did not include the purpose for disclosure.
Client # 2 was admitted on 1/17/17 and was still an active client at the time of the inspection. Consent to release forms were signed and dated on 1/24/17 to a probation officer, an external agency and the funding source, but none of them included the purpose for disclosures.
Client # 5 was admitted on 12/5/16 and was discharged on 3/31/17. A consent to release form was signed and dated on 12/22/16 to the funding source, but it did not include the purpose for the disclosure.
Client # 7 was admitted on 12/28/16 and was discharged on 5/2/17. Consent to release forms were signed and dated on 1/12/17 to the funding source and to a probation/parole office, but neither one of them included the purpose for the disclosures.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) For the active client mentioned in the deficiency, both consents for the PO and external funding source will be updated with the Purpose of the Disclosure on 6/22/17 during a scheduled appointment.
2) Director will review and train on 6/21/17 with Clinical Supervisor and CSS Supervisor on obtaining proper consents, including documentation of the specific purpose for disclosure.
3) Clinical Supervisor will conduct re-training on 6/29/17 to all counselors on obtaining proper consents, including documentation of the specific purpose for disclosure.
4) CSS Supervisor will train all Clinical Support Staff on 6/21/17 & 6/28/17 on obtaining proper consents, including documentation of the specific purpose for disclosure.
5) Clinical Supervisor will monitor the thorough completion of consents.
6) Facility Director will oversee thorough completion of consents from all program staff.
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on the review of the facility's unusual incident reports on May 26, 2017, the facility failed to notify the Department within 3 business days following the unusual incidents below, which were discovered during the licensing process.
The incident dates and incident reason are:
May 26, 2016 - Client's (offsite) death
December 14, 2016 - Ambulance presence requested
March 3, 2017 - Client's (offsite) death
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
1) Clinical Supervisor completed DDAP Unusual Incident Reports for all 3 incidents mentioned in the deficiency and submitted to DDAP on 6/12/17.
2) Clinical Supervisor will complete and submit any Unusual Incident Reports to DDAP within 3 business days, as applicable.
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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.
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Observations
Based on a review of client records, there were treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection in 2 of 6 records.
Client # 2 was admitted on 1/17/17 and was still an active client at the time of the inspection. The comprehensive treatment plan was completed on 2/22/17 with an update due no later than 4/22/17, however the update was completed 5/12/17.
Client # 6 was admitted on 11/7/16 and was discharged on 5/12/17. The comprehensive treatment plan was completed on 11/9/16 with an update due no later than 1/9/17. There was no update completed prior to discharge.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
?X 1) Clinical Supervisors will conduct in-service training on Treatment Planning on 6/8/17, which will include:
-Utilizing EHR effectively to track timely submission of Master Treatment Plan and Treatment Plan Updates
-How to properly update the status of current goals
-How to complete treatment goal reviews on progress or lack thereof
-How to update or create new or revised goals
?X 2) Clinical Supervisor will monitor the timely and thorough submission of Master and Updated treatment plans in supervisory sessions.
?X 3) Facility Director will oversee timely treatment plan completion from all program staff.
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