INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 April 19, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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, KARE Services, LLC dba Kolmac Outpatient Recovery 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 a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records reviewed.
Client # 3 was admitted on September 23, 2020 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 16, 2021; however, there was evidence of disclosures to the funding source documented in the record prior to the client signing the release form.
Client # 4 was admitted on October 3, 2019 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To correct this issue, our Chief compliance Officer will update our policies to reflect that our Office Manager will be responsible for auditing new patient charts to ensure no patient has failed to sign a required release. If a patient has not signed a release prior to admission, our Office Manager will join the patient's next remote telehealth session to have them complete the required documentation.
Our Clinical Director will train our administrative and clinical team on the importance of checking for a valid release of information every time, prior to releasing information.
Our Chief Compliance Officer will update our Clinical Chart Review form to add language about ensuring a release of information is signed prior to any information being released. Our Clinical Director will be responsible for completing chart reviews on a quarterly basis and this chart review process will serve as the oversight process we use to ensure compliance with the new policy.
Our Office Manager will have all clients listed in the deficiency sign updated releases by 6/4/2021.
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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 seven client records reviewed.
Client # 1 was admitted on December 10, 2020 and was still active at the time of the inspection. The release of information form to a family member was signed and dated by the client on December 11, 2021, but the release form failed to document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our Clinical Director will train all staff on properly completing releases of information and ensuring a valid release is on file every time prior to releasing information.
In the event we are unable to obtain a correctly completed release of information, our Office Manager will attend the patient's regularly scheduled session to help them complete the form.
Our Clinical Director will ensure compliance with this training and our policies through regular, quarterly chart reviews.
Our Office Manager will have all clients listed in the deficiency sign updated releases by 6/4/2021.
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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
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in one of seven client records reviewed.
Client # 1 was admitted on December 10, 2020 and was still active at the time of the inspection. A release of information form to the primary care physician was signed and dated by the client on January 26, 2021 and release of information forms to a family member, a pharmacy and the funding source were signed and dated by the client on December 11, 2021; however, all of the release forms failed to document the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our Clinical Director will train all staff on properly completing releases of information and ensuring a valid release is on file every time prior to releasing information.
In the event we are unable to obtain a correctly completed release of information, our Office Manager will attend the patient's regularly scheduled session to help them complete the form.
Our Clinical Director will ensure compliance with this training and our policies through regular, quarterly chart reviews.
Our Office Manager will have all clients listed in the deficiency sign updated releases by 6/4/2021.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review client records, the facility failed to document the dated signature of the client on a release of information form in three of seven client records reviewed.
Client # 1 was admitted on December 10, 2020 and was still active at the time of the inspection. The release of information forms to a family member, the pharmacy and the funding source were signed and dated by the witness on December 11, 2020, but the release forms did not include the dated signature of the client.
Client # 2 was admitted on September 16, 2020 and was still active at the time of the inspection. The release of information forms to a family member, the pharmacy and the funding source were signed and dated by the witness on September 17, 2020, but the release forms did not include the dated signature of the client.
Client # 7 was admitted on September 21, 2020 and was discharged on December 11, 2020. The release of information forms to a family member, the pharmacy, the primary care physician and the funding source were signed and dated by the witness on July 15, 2020, but the release forms did not include the dated signature of the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our Clinical Director will train all staff on properly completing releases of information and ensuring a valid release is on file every time prior to releasing information.
In the event we are unable to obtain a correctly completed release of information, our Office Manager will attend the patient's regularly scheduled session to help them complete the form.
Our Clinical Director will ensure compliance with this training and our policies through regular, quarterly chart reviews.
Our Office Manager will have all clients listed in the deficiency sign updated releases by 6/4/2021.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in six of seven client records reviewed.
Client # 1 was admitted on December 10, 2020 and was still active at the time of the inspection. The release of information form to the primary care physician was signed by the client on January 26, 2021. The release of information forms to a family member, the pharmacy and the funding source were signed by the client on December 11, 2020. The forms did not document that a copy of the consent was offered to the client.
Client # 2 was admitted on September 16, 2020 and was still active at the time of the inspection. The release of information form to a family member was signed by the client on March 31, 2021. The release of information forms to the pharmacy and the funding source were signed by the client on September 17, 2020. The forms did not document that a copy of the consent was offered to the client.
Client # 3 was admitted on September 23, 2020 and was still active at the time of the inspection. The release of information form to a family member was signed by the client on April 16, 2021 but it did not document that a copy of the consent was offered to the client.
Client # 4 was admitted on October 31, 2019 and was still active at the time of the inspection. The release of information forms to the primary care physician, another treatment provider and a family member were signed by the client on October 3, 2019 but they did not document that a copy of the consent was offered to the client.
Client # 6 was admitted on December 30, 2020 and was discharged on March 10, 2021. The release of information forms to the primary care physician and a family member were signed by the client on December 30, 2020 but they did not document that a copy of the consent was offered to the client.
Client # 7 was admitted on September 21, 2020 and was discharged on December 11, 2020. The release of information forms to the funding source, a family member, a pharmacy and the primary care physician were signed by the client on July 15, 2020 but they did not document that a copy of the consent was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our Chief Compliance Officer will update our Release of Information form to clearly indicate the release of information was offered to the client.
Our Clinical Director will train all staff on properly completing the new Release of Information form.
Our Office Manager will have all clients listed in the deficiency sign updated releases by 6/4/2021.
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709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment in three of seven client records reviewed.
Client # 1 was admitted on December 10, 2020 and was still active at the time of the inspection. The client rights acknowledgement documented in the record at the time of the inspection did not include the notification that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment.
Client # 5 was admitted on September 22, 2020 and was discharged on February 2, 2021. The client rights acknowledgement documented in the record at the time of the inspection did not include notification that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment.
Client # 7 was admitted on September 21, 2020 and was discharged on December 11, 2020. There was no client rights acknowledgement documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We had previously updated our client rights statement to exactly match DDAP regulations and we received confirmation that that the form was correct. It is possible we have some older clients that have an old version of the client rights statement. Our Chief Compliance Officer along with our Office Manager will ensure the correct, most recent version of the client right statement is in use and posted in the office.
Our Office Manager will have all clients listed in the deficiency sign updated client rights statements by 6/4/2021. |
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 client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that 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 in three of seven client records reviewed.
Client # 1 was admitted on December 10, 2020 and was still active at the time of the inspection. The client rights acknowledgement documented in the record at the time of the inspection did not include notification that that 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.
Client # 5 was admitted on September 22, 2020 and was discharged on February 2, 2021. The client rights acknowledgement documented in the record at the time of the inspection did not include notification that that 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.
Client # 7 was admitted on September 21, 2020 and was discharged on December 11, 2020. There was no client rights acknowledgement documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We had previously updated our client rights statement to exactly match DDAP regulations and we received confirmation from DDAP that the form was acceptable. It is possible we have some older clients that have an old version of the client rights statement. Our Chief Compliance Officer along with our Office Manager will ensure the correct, most recent version of the client right statement is in use and posted in the office.
Our Office Manager will have all clients listed in the deficiency sign updated client rights statements by 6/4/2021. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in three of seven client records reviewed.
Client # 1 was admitted on December 10, 2020 and was still active at the time of the inspection. The client rights acknowledgement documented in the record at the time of the inspection did not include notification that a client has the right to appeal a decision limiting access to their records to the director in the record.
Client # 5 was admitted on September 22, 2020 and was discharged on February 2, 2021. The client rights acknowledgement documented in the record at the time of the inspection did not include notification that a client has the right to appeal a decision limiting access to their records to the director in the record.
Client # 7 was admitted on September 21, 2020 and was discharged on December 11, 2020. There was no client rights acknowledgement documented in the record at the time of the inspection.
This is a repeat citation from the September 18, 2019 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We had previously updated our client rights statement to exactly match DDAP regulations and we received confirmation from DDAP that the form was acceptable. It is possible we have some older clients that have an old version of the client rights statement. Our Chief Compliance Officer along with our Office Manager will ensure the correct, most recent version of the client right statement is in use and posted in the office.
Our Office Manager will have all clients listed in the deficiency sign updated client rights statements by 6/4/2021. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in three of seven client records reviewed.
Client # 1 was admitted on December 10, 2020 and was still active at the time of the inspection. The client rights acknowledgement documented in the record at the time of the inspection did not include notification that a client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Client # 5 was admitted on September 22, 2020 and was discharged on February 2, 2021. The client rights acknowledgement documented in the record at the time of the inspection did not include notification that a client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Client # 7 was admitted on September 21, 2020 and was discharged on December 11, 2020. There was no client rights acknowledgement documented in the record at the time of the inspection.
This is a repeat citation from the September 18, 2019 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We had previously updated our client rights statement to exactly match DDAP regulations and we received confirmation from DDAP that the form was acceptable. It is possible we have some older clients that have an old version of the client rights statement. Our Chief Compliance Officer along with our Office Manager will ensure the correct, most recent version of the client right statement is in use and posted in the office.
Our Office Manager will have all clients listed in the deficiency sign updated client rights statements by 6/4/2021. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in three of seven client records reviewed.
Client # 1 was admitted on December 10, 2020 and was still active at the time of the inspection. The client rights acknowledgement documented in the record at the time of the inspection did not include notification that a client has the right to submit rebuttal data or memoranda to their own records.
Client # 5 was admitted on September 22, 2020 and was discharged on February 2, 2021. The client rights acknowledgement documented in the record at the time of the inspection did not include notification that a client has the right to submit rebuttal data or memoranda to their own records.
Client # 7 was admitted on September 21, 2020 and was discharged on December 11, 2020. There was no client rights acknowledgement documented in the record at the time of the inspection.
This is a repeat citation from the September 18, 2019 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We had previously updated our client rights statement to exactly match DDAP regulations and we received confirmation from DDAP that the form was acceptable. It is possible we have some older clients that have an old version of the client rights statement. Our Chief Compliance Officer along with our Office Manager will ensure the correct, most recent version of the client right statement is in use and posted in the office.
Our Office Manager will have all clients listed in the deficiency sign updated client rights statements by 6/4/2021. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to verify the individual's identity, including name, address and date of birth, prior to the administration of an agent in one of two applicable patient records reviewed.
Patient # 2 was admitted on September 16, 2020 and was still active at the time of the inspection. There was no documentation, in the client record, that the verification of the patient's identity was completed prior to the administration of an agent.
These findings were reviewed with facility staff during the licenisng process.
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Plan of Correction
We will begin a 2-step verification process to correct this issue. Our Front Desk and Medical personnel will each ask to see the patient's ID before they administer an injection. The medical staff will note that the ID was verified in the medical note they enter in the client's chart.
Our Chief Compliance Officer will update our policy manual to reflect these changes and Clinical Director will train staff.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in one of two applicable patient records reviewed.
Patient # 2 was admitted on September 16, 2020 and was still active at the time of the inspection. The record of service and progress notes showed that less than 2.5 hours of psychotherapy per month were provided during the following months:
- March 2021 - 2 hours documented
- March 2020 - 0 hours documented
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our Clinical Director will inform all narcotic treatment patients must attend 2.5 hours of psychotherapy per month during their first 2-years. Our Chief Compliance Officer will ensure our policy manual accurately reflects that requirements. Our Clinical Director will train all staff on the policy and how to accurately document services. |
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, the facility failed to review and update each client's treatment plan at least every 60 days in three of six applicable client records reviewed.
Client # 3 was admitted on September 23, 2020 and was still active at the time of the inspection. A treatment plan update was completed on November 13, 2020 and the next update was due no later than January 13, 2021; however, the update was not completed until February 17, 2021.
Client # 4 was admitted on October 3, 2019 and was still active at the time of the inspection. A treatment plan update was completed on October 1, 2020 and the next update was due no later than December 1, 2020; however, the update was not completed until February 4, 2021.
Client # 5 was admitted on September 22, 2020 and was discharged on February 2, 2021. The comprehensive treatment plan was completed on October 30, 2020, and the next update was due no later than December 30, 2020; however, the update was not completed until February 23, 2021, after the client was discharged.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Our Chief Compliance Officer will modify our electronic health record system to flag any patient who has a treatment plan update due within 7 days to ensure no patient goes longer than 60 days without a treatment plan update. Our Chief Compliance Officer will update our policy manual to reflect that change. In addition, our Chief Compliance Officer will update our quarterly Chart Review form to reflect that outpatient treatment plans be updated every 60 days. Our Clinical Director will train our clinical team on the policy and will complete the quarterly chart reviews to ensure compliance.
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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
Based on a review of client records, the facility failed to document follow up information in the client record in two of three applicable client records reviewed.
Client # 5 was admitted on September 22, 2020 and was discharged on February 2, 2021. The client record failed to document follow up information regarding the client as of the date of the inspection.
Client # 7 was admitted on September 21, 2020 and was discharged on December 11, 2020. The client record failed to document follow up information regarding the client as of the date of the inspection.
This is a repeat citation from the 2019 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our Chief Compliance Officer will create a report that shows what patients need follow up. Our Clinical Director will train staff on how to run the report and document that a follow up attempt was attempted. |