INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 21, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Spark Wellness 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 6 was admitted on June 4, 2024 and was discharged on July 29, 2024. There was evidence of disclosures to the funding source; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The correction for this is that the Clinical Director is going to be doing weekly chart checks of client paperwork to ensure that all consents are signed/completed in a timely manner. If there is a deficit in the timeliness of a consent being signed/completed, the Clinical Director will outreach the assigned clinician to let them know that it has to be completed within 72 hours of the communication being sent to the therapist. |
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 treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of five applicable client records reviewed.
Client # 3 was admitted on September 9, 2024 and was active at the time of inspection. The individual treatment plan was completed on November 4, 2024 and the first update was due no later than January 4, 2025; however, the update was not completed until February 19, 2025.
Client # 7 was admitted on April 1, 2024 and was discharged on June 19, 2024. The individual treatment plan was completed on April 11, 2024 and the first update was due no later than June 11, 2024; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The correction for this is that the Clinical Director is going to be doing weekly chart checks of client paperwork to ensure that all required clinical documentation is completed in a timely manner. The Clinical Director will outreach the assigned clinician to let them know that a treatment plan update is upcoming to be completed. |