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 January 11, 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, Wellness Recovery, 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to maintain the facility free of heaters that are not permanently mounted or installed.
During the physical plant inspection, conducted on January 11, 2021, client room #2 was observed to have a portable heater.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR current policy states no portable heaters. The 0n-duty counselor techs on 1/10 and 1/11 were notified by memo of their failure to recognize a portable heater was present in a patient room during shift check.
The Director of Operations will begin random room checks to verify accuracy and completion of room shift room checks. |
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, and an interview with facility staff, the facility failed to document an informed and voluntary consent for the release of information in four of four client records.
All four client records reviewed contained urine screen results documentation as well as documentation of a funding source. Client records #1, 2, 3 and 4 did not have documentation of a signed consent for urine screen testing and the funding source. An agreement between the facility and a lab was provided; however, it does not meet the requirements of a Qualified Service Organization Agreement that is in compliance with 42 CFR.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The release of information form now contains language that informs the client that their urine will be released to the lab for analysis. The form will be signed, dated and witnessed in the presence of the client. Additionally, WR has created a QSOA that meets CFR 42 with the lab New form and procedure has been immediately implemented and compliance is being monitored by the Director of Nursing and the Medical Director. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency or organization to whom disclosure will be made on the signed releases of information in client record #3.
Client #3 was admitted on November 17, 2020 and discharged on December 18, 2020. A signed consent to release information was documented in client record #3 that was blank, with the exception of the client signature and a purpose of "continuity of care."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR has an existing policy stating disclosures must include name, content and purpose of disclosure with expiration date. Policy was not followed in this case. Clinical staff have been re-trained in the procedure. Additionally, the release of consent form has been revised and separated from the consent for treatment form signed at intake. and will begin use on March 1, 2021. As stated, clinical staff have been instructed to complete the form with only when information is being released and include the person, agency, or organization.
The clinical director and CQI committee will monitor for compliance of the policy. |
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 the signed releases of information in client records #1 and 3.
Client #1 was admitted on December 12, 2020 and is currently and active client. A signed consent was documented in client record #1 that stated the information to be released was "two-way written communication" and "two-way verbal communication." The specific information to be released was not documented.
Client #3 was admitted on November 17, 2020 and discharged on December 18, 2020. A signed consent to release information was documented in client record #3 that was blank, with the exception of the client signature and a purpose of "continuity of care."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR has an existing policy stating disclosures must include name, specific content, purpose and specific information to be disclosed with expiration date for the release. Policy was not followed in this case. Clinical staff have been re-trained in the procedure. Additionally, the release of consent form has been revised to include information that is being disclosed.
The clinical director and CQI committee will monitor for compliance of the policy. |
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 for disclosure on the signed releases of information in client record #1.
Client #1 was admitted on December 12, 2020 and is currently an active client. A signed release of information, dated December 16, 2020 did not include a purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR has an existing policy stating that the purpose of disclosure must be included on the signed consent form. In this case our procedure was not followed. Clinical staff have been re-trained in the procedure.
The clinical director and CQI committee will monitor for compliance of the policy. |
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 of client records, the facility failed to document a dated signature of the client on the signed releases of information in client records #3.
Client #3 was admitted on November 17, 2020 and discharged on December 18, 2020. A signed consent to release information was documented in client record #3 that was blank, with the exception of the client signature and a purpose of "continuity of care."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR has an existing policy stating that client signature and date must be included on all release of information forms. Policy was not followed in this case. Clinical staff have been re-trained in the procedure.
The clinical director and CQI committee will monitor for compliance of the policy. |
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 a dated signature of the witness on the signed releases of information in client records #3.
Client #3 was admitted on November 17, 2020 and discharged on December 18, 2020. A signed consent to release information was documented in client record #3 that was blank, with the exception of the client signature and a purpose of "continuity of care."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR has an existing policy stating that a staff/witness must sign and date the release of information form in the presence of the client. Policy was not followed in this case.
The clinical director and CQI committee will monitor for compliance of the policy. |
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 a date, event or condition upon which the consent will expire on the signed releases of information in client records #3.
Client #3 was admitted on November 17, 2020 and discharged on December 18, 2020. A signed consent to release information was documented in client record #3 that was blank, with the exception of the client signature and a purpose of "continuity of care."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR has an existing policy stating that an expiration date, event or condition for release of information must appear on the release of information form. Policy was not followed in this case. Clinical staff have been re-trained in the procedure. Additionally, the release of consent form has been revised and separated from the consent for treatment form signed at intake and will begin use on March 1, 2021.
The clinical director and CQI committee will monitor for compliance of the policy. |
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 was offered to the client on the signed releases of information in client records #1, 2, 3 and 4.
All of the consents documented in client records #1, 2, 3 and 4 did not have documentation that a copy was offered to the client. There was no statement of a copy being offered on the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The signed release of information form has been redesigned and now includes a line for the client to initial that they have received a copy of the release of the release of information form. WR has a existing policy stating that clients should be provided with a copy of the release form. Policy was not followed in this case. Clinical staff have been re-trained in the procedure. New form will begin use on March 1, 2021.
The clinical director and CQI committee will monitor for compliance of the policy. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection, review of medication documentation and interviews with facility staff, the facility failed to document inspections of the medication storage area, including all areas required in 709.32 (c)(3)(i-v), at least quarterly.
A physical plant inspection and the medication storage inspection logs were requested on January 11, 2021. The licensing specialist was provided with various documents while onsite and also sent documents after the inspection; however, none of the documentation provided addresses all of the information required in 709.32 (c)(3)(i-v). The documentation provided focuses on medication counts and inventories.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new medication inspection log has been created and implemented on 3/1/2021. WR policy W-120 states that medication will be inspected twice per month on the 1st and 15th day of the month. The medication inspection log must be completed, signed and dated by 2 nurses during the inspection. The log now complies with 709.32.(c)i-V. The Director of Nursing is
responsible for compliance monitoring. |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on an interview with facility staff, the facility failed to file a written unusual incident report with the Department within 3 business days following the presence of ambulance personnel.
Interviews with staff occurred on January 11, 2021. Documentation of unusual incident reports was requested and the licensing specialist was informed that there weren't any. It was determined that ambulance personnel was present at the facility during the review period; however, no unusual incident report was sent to DDAP within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR policy W-116 requires DDAP notification for patients transported by ambulance as well as other unusual incidents. The procedure was not followed by staff on this day. Staff reported that because the transfer was non-emergency they didn't realize an incident report needed filed. On March 1, 2021, All personal have been notified by email with attached policy W-116 for re-education. The Clinical, Operations and Nursing Director are responsible for monitoring the policy compliance and filing the DDAP report. |
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
Based on a review of client records, the facility failed to document the type and frequency of services on the treatment plan in two of four client records.
Client #3 was admitted on November 17, 2020 and discharged on December 18, 2020. The individual treatment plan was completed on November 21, 2020. There was no frequency of individual therapy documented on the treatment plan in client record #3.
Client #4 was admitted on August 29, 2020 and discharged on September 25, 2020. The individual treatment plan was completed on September 8, 2020. There was no frequency of therapy services documented on the treatment plan in client record #4.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/1/2021 a new service plan tracker was added to all patient charts. Frequency and type of service has now been added to treatment plans. During weekly chart audits the CQI committee will monitor the service plan tracker and treatment plan for compliance. The clinical director will be responsible for compliance monitoring and follow through. WR policy T-130 outlines this procedure. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
Based on a review of client records and an interview with facility staff, the facility failed to document a complete record of services provided.
Client #1 was admitted on December 12, 2020 and is currently an active patient. The record of service documented only included individual therapy sessions. There was no record of service documented that included group therapy and psychoeducational groups.
Client #2 was admitted on December 26, 2020 and is currently an active patient. The record of service documented only included individual therapy sessions. There was no record of service documented that included group therapy and psychoeducational groups.
Client #3 was admitted on November 17, 2020 and discharged on December 18, 2020. The record of service documented only included individual therapy sessions. There was no record of service documented that included group therapy and psychoeducational groups.
Client #4 was admitted on August 29, 2020 and discharged on September 25, 2020. The record of service documented only included individual therapy sessions. There was no record of service documented that included group therapy and psychoeducational groups.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/1/2021 a new service plan tracker was added to all patient charts. This form will provide a record of all services delivered. Frequency and type of service has now been added to treatment plans. During weekly chart audits the CQI committee will monitor the service plan tracker and treatment plan for compliance. The clinical director will be responsible for compliance monitoring and follow through. WR policy T-130 outlines this procedure. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, facility policy and staff interviews, the facility failed to document case consultations 7 days after admission and every 30 days thereafter, as per facility policy.
Client #1 was admitted on December 12, 2020 and is currently an active patient. There were no case consults documented in client record #1.
Client #2 was admitted on December 26, 2020 and is currently an active patient. There were no case consults documented in client record #2.
Client #3 was admitted on November 17, 2020 and discharged on December 18, 2020. There were no case consults documented in client record #3.
Client #4 was admitted on August 29, 2020 and discharged on September 25, 2020. There were no case consults documented in client record #4.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR policy T-131 requires cases on day 7 and every 30 days or more often as needed. A case consultation form has been created and implemented on 3/1/2021. The form will be placed in all patient charts. Case consultations occur during the CQI weekly committee meeting and more often as needed. All clinical staff have been educated on the new form completion. The clinical director is responsible for T-131 compliance. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document discharge summary for two of two discharged clients.
Client #3 was admitted on November 17, 2020 and discharged on December 18, 2020. There was a discharge information form that was completed; however, it was not a summary, only demographic information and a description of where the client was going after discharge.
Client #4 was admitted on August 29, 2020 and discharged on September 25, 2020. There was a discharge information form that was completed; however, it was not a summary, only demographic information and a description of where the client was going after discharge
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR policy T-128 requires a discharge summary be completed on all patients. The procedure was not correctly followed in these cases. All counseling staff on 3/1/21 have been re-educated on the required components of the discharge summary to include reasons for treatment, services offered, response to treatment, and status at discharge. The clinical director through the CQI committee is responsible for monitoring compliance of T-128. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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, facility policy and staff interviews, the facility failed to document follow up information within 7 days as per facility policy in two of two client records.
Client #3 was admitted on November 17, 2020 and discharged on December 18, 2020. There was no follow up information documented in client record #3.
Client #4 was admitted on August 29, 2020 and discharged on September 25, 2020. There was no follow up information documented in client record #4.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR policy T-129 requires a follow-up at 7 days and 30 days be completed on all discharged patients. The procedure was not correctly followed in these cases. All counseling staff on 3/1/21 have been re-educated on the required follow-up and completion of the follow-up form. Clinical Coordinator is responsible for monitoring compliance of T-129. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records and an interview with facility staff, the facility failed to document that work completed by the client is part of their treatment and rehabilitation plan.
The treatment plans in client records #1, 2, 3 and 4 were reviewed. Work therapy was not documented on any of the treatment plans reviewed. Facility staff confirmed that household tasks are assigned to each client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/1/21 WR staff were trained to include work treatment in the in the treatment plan when that modality is used in the client treatment and rehabilitation plan of care.
The clinical director and CQI committee are responsible for monitoring treatment plans and compliance. |
709.14(b)(4) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(4) Change in activity/discontinuance of an activity.
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Observations
Based on a physical plant inspection, client record review and staff interviews, the facility is conducting narcotic treatment services utilizing buprenorphine without applying for and receiving the Department's approval. Per staff report, Buprenorphine treatment was first utilized starting in July 2020.
The findings were reviewed with facility staff during the inspection.
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Plan of Correction
WR has made application for a waiver. The facility has been notified by DDAP that the waiver application is under review and today 3/3/21 DDAP requested the DEA Buprenorphine authorization number of our medical director to finish processing the application. This information has been submitted to DDAP and we anticipate final approval soon.
Currently, the buprenorphine is being prescribed through our medical director who has an authorized personal DEA number for private use on WR patients. A private pharmacy fills the individual prescriptions.
In the event that DDAP does not grant a waiver to WR, WR will continue to utilize a private physician to prescribe the buprenorphine.
The medical director is responsible for follow with DDAP and for coordinating both private physician referral in lieu of the waiver. |