INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 17, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors who have not functioned for 2 years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed.
Employee #2 was hired as a clinical supervisor on October 31, 2022 and did not have any clinical supervision experience prior to being hired. There was no documentation of a Department-approved core curriculum in clinical supervision training in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will ensure the regulation is met by implementing the following measures:
1) We will add this requirement to the job description for the PA Clinical Supervisor so that incoming new hires or those promoted into the position are made aware of the requirement from the beginning.
2) We will add language regarding this requirement to offer letters for the PA Clinical Supervisor. This ensures they agree to this requirement as a condition of their hire or promotion into the position.
3) We will review this requirement with anyone hired or promoted into this position during orientation and training.
4) The Compliance Manager will reach out to any new PA Clinical Supervisors during their first week in the position to explain the requirement and provide the website and resources needed to enroll in the training. The Compliance Manager will also follow up and track the completion of this requirement to ensure it is fulfilled. Records of the completed training will be maintained in the employee's personnel file.
Employee #2 has completed the online portion of the Clinical Supervisor training and will attend the in-person session at the next available date. Employee #2 will be in compliance with this regulation before our next survey. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months in the position in one of one applicable personnel record reviewed.
Employee #2 was hired as a clinical supervisor on October 31, 2022. There were no monthly supervision notes documented in the record for the first 6 months in the position at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will ensure the regulation is met by implementing the following measures:
1) We will add this requirement to the job description for the PA Clinical Supervisor so that incoming new hires or those promoted into the position are made aware of the requirement from the beginning.
2) We will add language regarding this requirement to offer letters for the PA Clinical Supervisor. This ensures they agree to this requirement as a condition of their hire or promotion into the position.
3) This requirement will be reviewed with anyone hired or promoted into this position during orientation and training.
4) The Chief Clinical Officer will reach out to any new PA Clinical Supervisors during their first week in the position to explain the requirement and set up a schedule for supervision. Supervision records will be maintained in our EMR system and will be made available for inspection if requested.
5) The Compliance Manager will audit supervision documentation monthly to ensure it is being completed for the first 6 months the Clinical Supervisor is in this position.
The Chief Clinical Officer and Compliance Manager are responsible for the implementation of this corrective action. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that each counselor completed at least 25 hours of training annually in one of one applicable personnel record reviewed.
Employee #3 was hired on June 14, 2021. The personnel record documented 17 hours of annual training for the facility's January 2022 through December 2022 training year.
This is a repeat citation from the September 8, 2021 and August 15, 2022 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will ensure the regulation is met by implementing the following measures:
1) We will add this requirement to the job description for the PA Counselors so that incoming new hires or those promoted into the position are made aware of the requirement from the beginning.
2) We will add language regarding this requirement to offer letters for the PA Counselors. This ensures they agree to this requirement as a condition of their hire or promotion into the position.
3) This requirement will be reviewed with anyone hired or promoted into this position during orientation and training.
4) The Director of Clinical Training and Development will reach out to any new PA Counselors during their first week in the position to explain the requirement and review the opportunities for training within the company. It will be discussed with the counselor that if we cannot provide 25 clock hours of training internally, they would need to pursue external training opportunities to meet the requirement.
5) Internal trainings are tracked through our Learning Management System and can be provided if requested. We will collect certificates of completion to track external training.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's August 2022 through July 2023 fire drill logs, the facility failed to prepare alternate exit routes for each fire drill conducted. Each fire drill conducted during the reviewed period utilized the front door as the sole exit route.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will alternate using the front and back doors for monthly fire drills going forward. A log of all fire drills is kept onsite and will be reviewed by the Compliance Manager quarterly to ensure compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure manual, the facility failed to include, in their written procedures for the management of treatment/rehabilitation services to clients, a procedure regarding case consultation notes, specifically who is responsible for completing and the timeframe of completion.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will update their policy and procedure manual to include a section on case consultation that identifies who and how often the case consultation should be done. The Chief Clinical Officer and Director of Training and Development will work with the PA clinicians to establish a schedule for case consultation. All records of case consultation will be maintained in our EMR system and will be audited monthly during the chart review process to ensure completion. |
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 obtain an informed and voluntary consent to release information form prior to the disclosure of information in three of seven client records reviewed.
Client #1 was admitted on February 20, 2023 and was active at the time of 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 any of the disclosures.
Client #2 was admitted on December 12, 2022 and was active at the time of 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 any of the disclosures.
Client #3 was admitted on April 24, 2023 and was active at the time of 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 any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will update the ROI to include a section for funding sources/insurance carriers. This form will be available to all patients going forward to provide or waive their consent to release records to funding sources/insurance carriers. We will ensure we are using the new form if information or records are requested from funding sources/insurance carriers.
This will be added as an item to our checklist for monthly chart audits so we can monitor and ensure these are being completed. We will review with PA staff this new section of the ROI and ensure they are using the correct form to capture this consent.
The practice manager will review the new form with patients #1, #2 and #3 and will obtain their signature. |
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 release of information forms in three of seven client records reviewed.
Client #1 was admitted on February 20, 2023 and was active at the time of inspection. The release of information form to a primary care physician was signed and dated by the client on February 10, 2023; but the release form did not include specific information, as the form only indicated "full disclosure of any and all health information, including any SUD information."
Client #2 was admitted on December 12, 2022 and was active at the time of inspection. The release of information form to an emergency contact was signed and dated by the client on October 31, 2022, but the release form did not include the specific information to be disclosed.
Client #3 was admitted on April 24, 2023 and was active at the time of inspection. The release of information form to a primary care physician was signed and dated by the client on April 13, 2023; but the release form did not include specific information, as the form only indicated "full disclosure of any and all health information, including any SUD information."
This is a repeat citation from the September 8, 2021 and August 15, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will update the ROI to include a section indicating what specific information we are authorized to release. This form will be available to all patients going forward to provide or waive their consent to release specific information and records. We will ensure we are using the new form to identify the specific documents we can release.
This will be added as an item to our checklist for monthly chart audits so we can monitor and ensure these are being completed. We will review with PA staff this update to the ROI and ensure they are using the correct form to capture this consent.
The practice manager will review the new form with patients #1, #2 and #3 and will obtain their signature.
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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 release of information forms in one of seven client records reviewed.
Client #2 was admitted on December 12, 2022 and was active at the time of inspection. The release of information form to an emergency contact was signed and dated by the client on October 31, 2022, but the release form did not include the purpose of the disclosure.
This is a repeat citation from the September 8, 2021 and August 15, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will update the ROI form to include a section indicating the purpose for the disclosure. This form will be available to all patients going forward to provide or waive their consent to the purpose of the disclosure. We will ensure we are using the new form to identify the purpose of the disclosure.
This will be added as an item to our checklist for monthly chart audits so we can monitor and ensure these are being completed. We will review with PA staff this update to the ROI and ensure they are using the correct form to capture this consent.
The practice manager will review the new form with patient#2 and will obtain their signature. |
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 the date, event or condition upon which the consent will expire on release of information forms in one of seven client records reviewed.
Client #7 was admitted on July 16, 2021 and was discharged on January 5, 2023. The release of information form to a funding source was signed and dated by the client on July 16, 2021 and the form did not include an expiration date, event or condition to which it would expire.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will update the ROI form to include a section to indicate the date, event or condition upon which the consent will expire. This form will be available to all patients going forward to provide or waive their consent to release specific information until the date, event or condition they specify. We will ensure we are using the new form to indicate the expiration of the release.
This will be added as an item to our checklist for monthly chart audits so we can monitor and ensure these are being completed. We will review with PA staff this update to the ROI and ensure they are using the correct form to capture this consent.
The Compliance Manager is responsible for implementing this corrective action. |
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 ensure that a copy of a consent to release information form was offered to the client in one of seven client records reviewed.
Client #5 was admitted on September 15, 2021 and was discharged on August 4, 2023. The release of information form to the primary care physician was signed and dated by the client on June 10, 2021; however, there was no documentation that a copy of the form was offered to the client.
This is a repeat citation from the September 8, 2021 and August 15, 2022 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will update the policy and procedure manual to include a procedure for offering a copy of the signed ROI to the patient. We will update the ROI to include a section where the clinician or practice manager can document that they offered a copy of the consent to the patient.
This will be added as an item to our checklist for monthly chart audits so we can monitor and ensure these are being completed. We will review with PA staff this update to the ROI and ensure they are documenting that they offered the patient a copy of the consent.
The Compliance Manager is responsible for implementing this corrective action.
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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 acknowledgment by the client that the client had been informed of their right to retain civil rights and liberties except as provided by statute in three of seven client records reviewed.
Client #1 was admitted on February 20, 2023 and was active at the time of inspection.
Client #2 was admitted on December 12, 2022 and was active at the time of inspection.
Client #3 was admitted on April 24, 2023 and was active at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will add the specific Department language for patient rights to its Patient Rights Policy. We will also update the form in our EMR that patients sign to acknowledge they have received, read and understand their rights to include the Department specific language.
This will be added as an item to our checklist for monthly chart audits so we can monitor and ensure the correct form is being used and acknowledged for all patients. We will review with PA staff this update to the Patient Rights and ensure they are using the correct form.
The Practice Manager will review the new patient's rights form with patients #1, #2, and #3 and will obtain their signature.
The Compliance Manager is responsible for implementing this corrective action. |
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 the client that the client had been informed 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 February 20, 2023 and was active at the time of inspection.
Client #2 was admitted on December 12, 2022 and was active at the time of inspection.
Client #3 was admitted on April 24, 2023 and was active at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will add the specific Department language for patient rights to its Patient Rights Policy. We will also update the form in our EMR that patients sign to acknowledge they have received, read and understand their rights to include the Department specific language.
This will be added as an item to our checklist for monthly chart audits so we can monitor and ensure the correct form is being used and acknowledged for all patients. We will review with PA staff this update to the Patient Rights and ensure they are using the correct form.
The Practice Manager will review the new patient's rights form with patients #1, #2, and #3 and will obtain their signature.
The Compliance Manager is responsible for implementing this corrective action. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgment by the client that the client had been informed of their right to inspect their own records in three of seven client records reviewed.
Client #1 was admitted on February 20, 2023 and was active at the time of inspection.
Client #2 was admitted on December 12, 2022 and was active at the time of inspection.
Client #3 was admitted on April 24, 2023 and was active at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will add the specific Department language for patient rights to its Patient Rights Policy. We will also update the form in our EMR that patients sign to acknowledge they have received, read and understand their rights to include the Department specific language.
This will be added as an item to our checklist for monthly chart audits so we can monitor and ensure the correct form is being used and acknowledged for all patients. We will review with PA staff this update to the Patient Rights and ensure they are using the correct form.
The Practice Manager will review the new patient's rights form with patients #1, #2, and #3 and will obtain their signature.
The Compliance Manager is responsible for implementing this corrective action. |
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 acknowledgment by the client that the client had been informed 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 February 20, 2023 and was active at the time of inspection.
Client #2 was admitted on December 12, 2022 and was active at the time of inspection.
Client #3 was admitted on April 24, 2023 and was active at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will add the specific Department language for patient rights to its Patient Rights Policy. We will also update the form in our EMR that patients sign to acknowledge they have received, read and understand their rights to include the Department specific language.
This will be added as an item to our checklist for monthly chart audits so we can monitor and ensure the correct form is being used and acknowledged for all patients. We will review with PA staff this update to the Patient Rights and ensure they are using the correct form.
The Practice Manager will review the new patient's rights form with patients #1, #2, and #3 and will obtain their signature.
The Compliance Manager is responsible for implementing this corrective action. |
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 acknowledgment by the client that the client had been informed 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 February 20, 2023 and was active at the time of inspection.
Client #2 was admitted on December 12, 2022 and was active at the time of inspection.
Client #3 was admitted on April 24, 2023 and was active at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will add the specific Department language for patient rights to its Patient Rights Policy. We will also update the form in our EMR that patients sign to acknowledge they have received, read and understand their rights to include the Department specific language.
This will be added as an item to our checklist for monthly chart audits so we can monitor and ensure the correct form is being used and acknowledged for all patients. We will review with PA staff this update to the Patient Rights and ensure they are using the correct form.
The Practice Manager will review the new patient's rights form with patients #1, #2, and #3 and will obtain their signature.
The Compliance Manager is responsible for implementing this corrective action. |
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 acknowledgment by the client that the client had been informed 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 February 20, 2023 and was active at the time of inspection.
Client #2 was admitted on December 12, 2022 and was active at the time of inspection.
Client #3 was admitted on April 24, 2023 and was active at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will add the specific Department language for patient rights to its Patient Rights Policy. We will also update the form in our EMR that patients sign to acknowledge they have received, read and understand their rights to include the Department specific language.
This will be added as an item to our checklist for monthly chart audits so we can monitor and ensure the correct form is being used and acknowledged for all patients. We will review with PA staff this update to the Patient Rights and ensure they are using the correct form.
The Practice Manager will review the new patient's rights form with patients #1, #2, and #3 and will obtain their signature.
The Compliance Manager is responsible for implementing this corrective action. |
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 review of the policy and procedure manual, the facility failed to include, in their medication policies, a policy and procedures regarding the inspection of storage areas that ensures compliance with State and Federal laws and program policy including: 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; disinfectants and drugs for external use are stored separately from oral and injectable drugs; drugs requiring special conditions for storage to insure stability are properly stored; outdated drugs are removed; copies of drug-related regulations are available in appropriate areas.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will update its Medication policy to include procedures for inspection of storage areas. This policy will be shared with staff, who will acknowledge they have read and understand the policy. We utilize compliance software, Healthicity, as our main method for training and policy acknowledgement. Staff will be assigned the policy to read and electronically acknowledge.
The Medical Director will review the inspection checklist, temperature log and medication log on a quarterly basis to ensure compliance with our policy.
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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, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in five of six applicable client records reviewed.
Client #1 was admitted on February 20, 2023 and was still active at the time of the inspection. A treatment plan update was completed on May 4, 2023 and the next update was due no later than July 4, 2023; however, the update was not completed until July 21, 2023.
Client #4 was admitted on April 26, 2021 and was discharged on January 31, 2023. A treatment plan update was completed on June 16, 2022 and the next update was due no later than August 16, 2022; however, the update was not completed prior to discharge.
Client #5 was admitted on September 15, 2021 and was discharged on August 4, 2023. A treatment plan update was completed on August 18, 2022, and the next update was due no later than October 18, 2022; however, the update was not completed until November 18, 2022. Additionally, a treatment plan update was completed on November 18, 2022 and the next update was due no later than January 18, 2023; however, the update was not completed until February 17, 2023.
Client #6 was admitted on September 19, 2022 and was discharged on March 24, 2023. A treatment plan update was completed on November 16, 2022, and the next update was due no later than January 16, 2023; however, the update was not completed prior to discharge.
Client #7 was admitted on July 16, 2021 and was discharged on January 5, 2023. A treatment plan update was completed on March 17, 2022, and the next update was due no later than May 17, 2022; however, the update was not completed until October 13, 2022.
This is a repeat citation from the August 15, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will ensure this regulation is met by providing a refresher training on treatment planning and adhering to the required interval for treatment plan updates. We will also update our Polices and Procedures to include information on this requirement. If the patient is not able to meet at the 60 day mark to review and sign the treatment plan update, the clinician will:
1) Complete the treatment plan at the 60 day mark. They will review with patient and have them sign at the next earliest session.
2) Make a notation in the patient's chart that the treatment plan was completed at the required interval, but patient was not able to review and sign on that day.
We also have the ability to set up notifications to staff when a treatment plan is coming due for an update to assist them with planning for these updates.
This will be added as an item to our checklist for monthly chart audits so we can monitor and ensure that treatment plans are being updated in accordance with the Department's required frequency.
The Compliance Manager and Chief Clinical Officer are responsible for implementing this corrective action. |
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 a complete client record, which is to include follow-up information, in three of four applicable records reviewed.
Client #4 was admitted on April 26, 2021 and was discharged on January 31, 2023. There was no follow-up information documented in the record as of the date of the inspection.
Client #6 was admitted on September 12, 2022 and was discharged on March 24, 2023. There was no follow-up information documented in the record as of the date of the inspection.
Client #7 was admitted on July 16, 2021 and was discharged on January 5, 2023. There was no follow-up information documented in the record as of the date of the inspection.
This is a repeat citation from the September 8, 2021 and August 15, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac will update its documentation requirements and policy to include documentation of follow up after the patient discharges from our care. The information should include connecting with a referral source if applicable. Kolmac will add a form in its EMR system specifically for follow up.
This will be added as an item to our checklist for monthly chart audits so we can monitor and ensure that patient follow up is being documented appropriately.
The Compliance Manager and Chief Clinical Officer are responsible for implementing this corrective action. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for ensuring the client is offered a copy of a consent to release information form were submitted and approved by the Department for the August 15, 2022 and September 8, 2021 annual licensing inspections. Not documenting that a copy of consent to release information forms were offered to the client was again found to be a deficiency in the August 17, 2023 licensing inspection.
Plans of correction for documenting follow-up information in a complete client record were submitted and approved by the Department for the August 15, 2022 and September 8, 2021 annual licensing inspections. Not documenting follow-up information was again found to be a deficiency in the August 17, 2023 licensing inspection.
Plans of correction for documenting specific information to be released on consent to release information forms were submitted and approved by the Department for the August 15, 2022 and September 8, 2021 annual licensing inspections. Not documenting the specific information to be released on consent forms was again found to be a deficiency in the August 17, 2023 licensing inspection.
Plans of correction for documenting the purpose of disclosure on consent to release information forms were submitted and approved by the Department for the August 15, 2022 and September 8, 2021 annual licensing inspections. Not documenting the purpose of disclosure on consent forms was again found to be a deficiency in the August 17, 2023 licensing inspection.
Plans of correction for documenting the completion of 25 annual training hours for counselors were submitted and approved by the Department for the August 15, 2022 and September 8, 2021 annual licensing inspections. Not ensuring the completion of 25 annual training hours for counselors was again found to be a deficiency in the August 17, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Specific plan of correction measures for each of the repeat deficiencies were noted for each item. Below is our plan for how we intend to comply with the plan of correction approved by the Department.
Kolmac will first review all deficiencies identified by the Department with clinical and facility leadership so there is an understanding of the items we need to correct. We will solicit input on how we can best resolve the issues and monitor ourselves to ensure consistency and adherence to the plan of correction and all Department regulations.
Kolmac has appointed a new Compliance Manager and is currently recruiting to add an additional member to the Compliance Team. Increasing the bandwidth in this department will enable our organization to provide greater oversite and monitoring to ensure our plan of correction measures are being implemented and actioned consistently.
For items specifically related to patient chart documentation, we will implement the following actions to ensure we are compliant with our plan of correct and the Department's regulations.
Patient Consent for the Release of Information
Deficiencies ? No documentation of offering copy of consent to patient, consent form missing the specific information to be released, consent form missing the purpose of the release.
We will work with our IT team to update the ROI form in our EMR to include a space to indicate a copy was offered to the patient, the specific information we can release and the purpose of the release. Once the form is updated, training will be provided to staff on how this form is to be used. The form will be made available to all new and existing patients. We will conduct monthly chart audits to ensure this form is being used consistently. No information will be released without a complete and correct consent on file. All requests for records will flow through the Compliance Manager, who will be responsible for ensuring the correct consent is on file before the records are released.
Follow Up Not Documented in Charts
Deficiencies ? Follow-up documentation when patient is discharged is not present in the patient charts.
Kolmac will revise its policies on documentation to include follow up when the patient is discharged. We will add a Follow Up Note form in the EMR to document these actions in the patient chart.
Training will be provided to staff on what information to include in follow-up notes and when to complete this documentation. We will conduct monthly chart audits to ensure staff are documenting this appropriately in the chart.
Training Requirement for Counselors
Kolmac will make all PA counselors and clinical leaders aware of the requirements for 25 clock hours of training each year. We intend to add language to our offer letters and job descriptions so that employees are aware of the requirement from the very beginning of their employment.
Training provided by Kolmac is tracked through our learning management system and a report can be generated to show what trainings employees have taken. We will require all counselors to send us copies of completion certificates for any external training they take. All training for PA counselors will be tracked by our Director of Clinical Training and Development, who will follow up quarterly to review the progress towards completing the required hours of training.
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