INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, 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 September 9-10, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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, Brookdale 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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709.30 (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 twelve client records on September 9, 2020 and September 10, 2020, the project failed to develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. 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.The project ' s policies and procedures each client signed off on failed to include that the project may not discriminate in the provision of services on the basis of ethnicity and marital status.This information was reviewed with project staff during the licensing process.
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Plan of Correction
Clients #1 through 12 were discharged at the tine of DDAP POC due date.
The Director of Compliance revised the patient rights so they include that the project may not discriminate in the provision of services based on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
On September 10, 2020, the Director of Compliance added "ethnicity and marital status" to Patient Rights.
The Director of Compliance will review the project's policies and procedures annually to align with DDAP regulations and ensure ongoing compliance.
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709.62(c)(2)(ii) LICENSURE Orientation - Op hours
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of three client records on September 9, 2020 and September 10, 2020, the facility failed to provide documentation of a client orientation to the project which includes a familiarization with the hours of operation.Client #1 was admitted on July 9, 2020 and discharged on July 12, 2020; the facility failed to document a client orientation to the project which includes a familiarization with the hours of operation.Client #2 was admitted on October 10, 2019 and discharged on October 15, 2010; the facility failed to document a client orientation to the project which includes a familiarization with the hours of operation.Client #3 was admitted on January 7, 2020 and discharged on February 6, 2020; the facility failed to document a client orientation to the project which includes a familiarization with the hours of operation.This information was reviewed with project staff during the licensing process.
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Plan of Correction
Clients #1, #2 and #3 were discharged at the time of DDAP POC was due.
The Director of Compliance will revise the Patient Orientation Acknowledgment Form to include the Hours of Operation.
On September 10, 2020, the Director of Compliance added "Hours of Operation" to the Patient Orientation Acknowledgment Form.
The Director of Compliance will review the project's forms annually against DDAP regulations to ensure ongoing compliance.
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709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of nine client records on September 9, 2020 and September 10, 2020, the project failed to provide documentation of a client orientation to the project which includes a familiarization with the hours of operation.Client #4 was admitted on August 21, 2020 and was current at the time of the inspection. The project failed to document a client orientation to the project which includes a familiarization with the hours of operation.Client #5 was admitted on March 4, 2020 and discharged on April 29, 2020. The project failed to document a client orientation to the project which includes a familiarization with the hours of operation.Client #6 was admitted on February 11, 2020 and discharged on March 13, 2020. The project failed to document a client orientation to the project which includes a familiarization with the hours of operation.Client #7 was admitted on May 12, 2020 and discharged on June 6, 2020. The project failed to document a client orientation to the project which includes a familiarization with the hours of operation.Client #8 was admitted on March 24, 2020 and discharged on April 20, 2020. The project failed to document a client orientation to the project which includes a familiarization with the hours of operation.Client #9 was admitted on August 24, 2020 and was current at the time of the inspection. The project failed to document a client orientation to the project which includes a familiarization with the hours of operation.Client #10 was admitted on August 25, 2020 and was current at the time of the inspection. The project failed to document a client orientation to the project which includes a familiarization with the hours of operation.Client #11 was admitted on April 4, 2020 and discharged on May 2, 2020. The project failed to document a client orientation to the project which includes a familiarization with the hours of operation.Client #12 was admitted on August 20, 2020 and was current at the time of the inspection. The project failed to document client orientation to the project which includes a familiarization with the hours of operation.This information was reviewed with project staff during the licensing process.
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Plan of Correction
Clients #1, #4, #5,#6, #9, #10, #11, #12 were discharged at the time DDAP POC was due.
The Director of Compliance will revise the Patient Orientation Acknowledgment Form to include the Hours of Operation.
On September 10, 2020, the Director of Compliance added "Hours of Operation" to the Patient Orientation Acknowledgment Form.
The Director of Compliance will review the project's forms annually against DDAP regulations to ensure ongoing compliance.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of twelve client records on September 9, 2020 and September 10, 2020, the facility failed to develop intake procedures that include documentation of an appropriate psychosocial evaluation.Client #1 was admitted on July 9, 2020 and discharged on July 12, 2020. The facility failed to include documentation of an appropriate psychosocial evaluation.Client #4 was admitted on August 21, 2020 and was current at the time of the inspection. The facility failed to include documentation of an appropriate psychosocial evaluation.Client #6 was admitted on February 11, 2020 and discharged on March 13, 2020. The facility failed to include documentation of an appropriate psychosocial evaluation.Client #9 was admitted on August 24, 2020 and was current at the time of the inspection. .The facility failed to include documentation of an appropriate psychosocial evaluation.Client #10 was admitted on August 25, 2020 and was current at the time of the inspection. The facility failed to include documentation of an appropriate psychosocial evaluation.Client #11 was admitted on April 4, 2020, discharged on May 2, 2020. The facility failed to include documentation of an appropriate psychosocial evaluation.Client #12 was admitted on August 20, 2020 and was current at the time of the inspection. The facility failed to include documentation of an appropriate psychosocial evaluation.This information was reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #1, #4, #6, #9, #10, #11, #12 were discharged at the time DDAPPOC was due.
The Clinical Director will conduct an in-service training for the counseling staff on a comprehensive and appropriate psychosocial evaluation.
On September 14, 2020, the Clinical Director conducted an in-service training for the counseling staff on a comprehensive and appropriate psychosocial evaluation.
Persons Responsible: The Clinical Director and Director of Compliance will conduct monthly tracers to ensure the counseling staff are adhering to a comprehensive psychosocial evaluation.
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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
Based on a review of twelve client records on September 9, 2020 and September 10, 2020, the facility failed to develop individual treatment and rehabilitation plans with nine clients that included type of treatment and rehabilitation services.Client # 4 was admitted on August 21, 2020 and was current at the time of the inspection. The treatment and rehabilitation plan dated August 27, 2020 did not include the type of treatment and rehabilitation services.Client #5 was admitted on March 4, 2020 and discharged on April 29, 2020. The treatment and rehabilitation plans dated March 4, 2020 and March 12, 2020 did not include the type of treatment and rehabilitation services.Client #6 was admitted on February 11, 2020, discharged on March 13, 2020 and the treatment and rehabilitation plan dated February 14, 2020 did not include the type of treatment and rehabilitation services.Client #7 was admitted on May 12, 2020 and discharged on June 6, 2020. The treatment and rehabilitation plan dated May 13, 2020 did not include the type of treatment and rehabilitation services.Client #8 was admitted on March 24, 2020 and discharged on April 20, 2020. The treatment and rehabilitation plan dated March 25, 2020 did not include the type of treatment and rehabilitation services.Client #9 was admitted on August 24, 2020 and was still current at the time of the inspection. The treatment and rehabilitation plan dated August 27, 2020 did not include the type of treatment and rehabilitation services.Client #10 was admitted on August 25, 2020 and was current at the time of the inspection. The treatment and rehabilitation plan dated August 26, 2020 did not include the type of treatment and rehabilitation services.Client #11 was admitted on April 4, 2020 and discharged on May 2, 2020. The treatment and rehabilitation plan dated April 7, 2020 did not include the type of treatment and rehabilitation services.Client #12 was admitted on August 20, 2020 and was a current client at the time of the inspection. The treatment and rehabilitation plan dated August 20, 2020 did not include the type of treatment and rehabilitation services.This information was reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #4 through #12 were discharged at the time DDAP POC was due.
The Clinical Director will conduct an in-service training for the counseling staff on the development of a treatment plans to include type of treatment and rehabilitation services.
On September 14, 2020, the Clinical Director conducted an in-service training for the counseling staff on treatment plans to include type of treatment and rehabilitation services.
Persons Responsible: The Clinical Director and Director of Compliance will conduct monthly tracers to ensure the counseling staff are including the type of treatment and rehabilitation services to the treatment plans.
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