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 1, 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, The Empowerment Resurrection Center 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 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on an inspection of the project on September 1, 2020, the project failed to follow its client record policy to secure hard copy client records within locked storage containers. When the inspector arrived at the project no client records were being secured onsite. The project was storing confidential client records on volunteer's personal laptop computers offsite. The project ' s CEO left the facility to obtain a volunteer ' s laptop for client records to be reviewed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
AS of 12/01/2020, ERC will utilize KIPU systems to secure client records which will be stored on their cloud based system. The program director will ensure security is maintained and users of the system will utilize a two step process to ensure confidentiality of client records. There will be a computer for all staff to utilize.
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709.30 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.
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Observations
Based on a review of records on September 1, 2020, the project failed to document written acknowledgement that the clients had been notified of their client rights in three out of three records reviewed.
Client #1 was admitted on January 24, 2020 and was still current at the time of the inspection. There was no written documentation that client #1 had been notified of their client rights at the time of the inspection.
Client #2 was admitted on January 15, 2020 and was still current at the time of the inspection. There was no written documentation that client #2 had been notified of their client rights at the time of the inspection.
Client #3 was admitted on December 10, 2019 and was discharged on March 12, 2020. There was no written documentation that client #3 had been notified of their client rights at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of 12/01/20 ERC will develop written policies and procedure on client's right and document written acknowledgment by the client that they have been notified of these rights by signed acknowledgment. The program director and primary counselor will ensure the client is informed of their rights during the intake process. This will be verified with the clients signature at intake. Current clients will have clients rights reviewed with them as of 12/01/2020.
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an onsite inspection on September 1, 2020, the project failed to produce a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project 's performance in relationship to its stated goals and objectives.
During the scheduled onsite inspection, the project took several hours to retrieve client data which was kept on a volunteer's personal laptop outside of the licensed project.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
AS of 12/01/2020, ERC will use KIPU software data systems, a secure, cloud-based solution, that supports clinical data collection and record keeping requirements. This system will allow for efficient retrieval, record management and necessary measures project's clinical performance. Clinicians will utilize program issued PCs, phones or tablets. The sign in process is a two step process which ensures client records are secure. The program director will verify the two step sign in process is being utilized by all users of the system.
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709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records on September 1, 2020, the project failed to orient one out of three clients to project policies.
Client #2 was admitted on January 15, 2020 and was still current at the time of the inspection. There was no documentation at the time of the inspection that client #2 had been oriented to project policies.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of 12/01/2020 ERC Will update intake procedure to include documentation of client orientation to ERC IOP which include familiarization with our project policies. Clients and counselors will sign off on all necessary documents during intake prior to admission to the program. The program director will ensure documents are signed during monthly audits of client records. Current clients will sign all necessary documents as of 12/01/2020.
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709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records on September 1, 2020, the project failed to orient one out of three clients to the hours of operation.
Client #2 was admitted on January 15, 2020 and was still current at the time of the inspection. There was no documentation at the time of the inspection that client #2 had been oriented to the hours of operation.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of 12/01/2020 ERC will update intake procedure to include documentation of client orientation to ERC IOP which include familiarization with ERC hours of operations during the client's intake process. The program director will ensure hours of operation are also properly displayed on the door of the ERC office in accordance with DDAP policies. Also, as of 12/01/2020 all current clients will sign off to verify they have been informed of the hours of operation.
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709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records on September 1, 2020, the project failed to orient one out of three clients to the fee schedule.
Client #2 was admitted on January 15, 2020 and was still current at the time of the inspection. There was no documentation at the time of the inspection that client #2 had been oriented to the fee schedule.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of 12/01/2020, ERC will update intake procedure to include documentation of client orientation to ERC IOP which include familiarization with ERC fee schedule. The program director will ensure clients sign off on documentation which verifies they were notified of the fee schedule during the intake process through monthly audits of client records. All current clients will sign off as of 12/01/2020.
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709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records on September 1, 2020, the project failed to orient one out of three clients to services provided.
Client #2 was admitted on January 15, 2020 and was still current at the time of the inspection. There was no documentation at the time of the inspection that client #2 had been oriented to services provided.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of 12/01/2020 ERC will update intake procedure to include documentation of client orientation to ERC IOP which include familiarization to ERC services provided. All current clients will sign off on this procedure as of 12/01/2020. New clients will be oriented during intake and admission process. Moving forward, the Program director will ensure this procedure is being followed through monthly audits of clients records.
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records on September 1, 2020, the project failed to complete a medical history in two out of three client records.
Client #2 was admitted on January 15, 2020 and was still current at the time of the inspection. At the time of the inspection, Client #2 had no documented medical history.
Client #3 was admitted on December 10, 2019 and was discharged on March 12, 2020. At the time of the inspection, Client #3 had no documented medical history.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
AS of 12/01/2020, ERC will update intake procedure to include documentation of client medical history during the intake and admission process. All current clients will be updated and have documented medical history as of 12/01/2020.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records on September 1, 2020, the project failed to obtain consent to treatment in three out of three client records.
Client #1 was admitted on January 24, 2020 and was still current at the time of the inspection. Client #1 did not have documentation that consent for treatment had been obtained.
Client #2 was admitted on January 15, 2020 and was still current at the time of the inspection. Client #2 did not have documentation that consent for treatment had been obtained.
Client #3 was admitted on December 10, 2019 and was discharged on March 12, 2020. Client #3 did not have documentation that consent for treatment had been obtained.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
AS of 12/01/2020 ERC will update intake procedure to include consent to treatment. All current clients will sign consent to treatment by 12/01/2020. Moving forward, the program director will ensure all clients sign consent to treatment during the intake process. This will be verified through monthly audits of client records.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on September 1, 2020, the project failed to document a psychosocial evaluation in one of three client records reviewed.
Client #3 was admitted on December 10, 2019 and discharged on March 12, 2020. There was no documentation of a psychosocial evaluation in the client record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
AS of 12/01/2020
ERC will update intake procedure to include psychosocial evaluation. All current clients will receive a psychosocial evaluation as of 12/01/2020. Moving forward the program director will ensure a psychosocial evaluation is completed within the first two weeks of admission. This will be verified through monthly audits of client records.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records on September 1, 2020, the project failed to document a preliminary treatment and rehabilitation plan in one out of three records reviewed.
Client #1 was admitted on January 15, 2020 and was still current at the time of the inspection. Client #1 had no documented preliminary treatment and rehabilitation plan at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
AS of 12/01/2020
ERC will update intake procedure to include documentation of preliminary treatment and rehabilitation plan. All current client records will be updated at of 12/01/2020. Moving forward, the Program director will ensure records are updated in accordance with DDAP policies through monthly audits of client records. Initial treatment plans will be completed within first two weeks or 2 sessions after admission (whichever comes first).
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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 on September 1, 2020, the project failed to review and update treatment and rehabilitation plans every 60 days in three out of three client records.
Client #1 was admitted on January 24, 2020 and was still current at the time of the inspection. Client #1 had no documented preliminary treatment and rehabilitation plan at the time of the inspection. Client #1 also had no treatment and rehabilitation plan updates every 60 days.
Client #2 was admitted on January 15, 2020 and was still current at the time of the inspection. Client #2 had a preliminary treatment and rehabilitation plan dated January 21, 2020. Client #2 should have had treatment and rehabilitation plan updates no later than March 21, 2020, May 21, 2020 and July 21, 2020. Client #2 had no treatment and rehabilitation plan updates at the time of the inspection.
Client #3 was admitted on December 10, 2019 and was discharged on March 12, 2020. Client #3 had a preliminary treatment and rehabilitation plan dated December 10, 2019. Client #3 should have had a treatment and rehabilitation plan update no later than February 10, 2020, however there was no treatment and rehabilitation plan update documented at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
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Treatment and rehabilitation services:
ERC treatment and rehabilitation plan will be reviewed and updated at least every 60 days in the medical record.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records on September 1, 2020, the project failed to assure that counseling services were provided according to a client on a regular and scheduled basis in two out of three client records. The project ' s CEO reported both Client #1 and #2 were still actively participating in counseling with the project. However, the project failed to maintain documentation of counseling.
Client # 1 was admitted on January 24, 2020 and was still current at the time of the inspection. Client # 1 ' s last documented counseling session was on February 25, 2020.
Client # 2 was admitted on January 15, 2020 and was still current at the time of the inspection. Client # 2 ' s last documented counseling session was on March 9, 2020.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
ERC will maintain a complete client record on individual information relative to his involvement in the program. ERC will follow treatment plan and document in the form of a progress note. All client records will be updated by 12/01/2020. The program director will ensure all current client records are updated by above date and moving forward, the program director will ensure progress notes are updated through monthly audits of client records. |
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 on September 1, 2020, the project failed to have a complete client record on one individual which includes information relative to the client's involvement with the project including follow-up information.
Client #3 was admitted on December 10, 2019 and was discharged on 3/12/2020. Client #3 had no follow-up documented in the client record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
AS of 12/01/2020, ERC will develop the following aftercare and follow up policy:
The Clinical Supervisor or Counselor will follow-up interview with each client who graduates from the Intensive Outpatient Program on a monthly basis. The contact should be done by phone or in a face to face meeting. However, the client may be mailed or emailed surveys to be returned to the facility. The Counselor will take post program notes to be kept in the client's file.
Timeline for Graduates
Counselor follow-up interview will be conducted in the following timeline:
Once per month for the first 6 months after discharge
Once every 3 months for the next 12 months (month 6-18)
Once every 6 months for remainder of 2nd year.
Timeline for Involuntary/Voluntary Discharged Clients
Counselor follow-up interview will be conducted in the following timeline:
Once per month for 1st 3 months
Once every 3 months thereafter up to 1 year after discharge
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