INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on October 12, 2022 through October 13, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard Return Program 1 & 2 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) (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 is made on consent to release information forms in seven of seven client records reviewed.
Each client record reviewed contained a release of information form to the "probation and parole department"; however, each release form, in every record, did not include the specific name of the person, agency, or organization to whom disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1.The Probation and Parole release will be updated to require the inclusion of the officer's name or the county/state where the probation is in effect.
a. Responsible party -VP Operation?
Completion date ?11-1-2022
2.All staff will receive in-service training on the accurate completion of the form
a. Responsible Party-Clinical Supervisor-
Completion date- 11-15-2023
3.The clinical supervisor will conduct a
60-day focus review to ensure that all
forms are accurately completed
4. Clinical supervisors will perform an individual supervision with counselor of client 4 and all staff on procedure and policy on completions ROI
Responsible Party-Clinical
Supervisor-
Completion date- 11-15-2022
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, which is to also include the reason for termination, in two of two applicable client records reviewed.
Client # 5 was admitted on January 31, 2022 and was administratively discharged on March 28, 2022. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
Client # 6 was admitted on February 11, 2022 and was administratively discharged on February 26, 2022. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Clinical Supervisor will retrain the staff on the protocol in carrying out an Administrative Discharge i.e. notification of termination. All staff will receive the written policy and will sign the attendance sheet verifying that they were trained in the correct protocol.
a. Responsible party ?Clinical
supervisor
Completion date 11/1/2022
2. Clinical Supervisor will add Discharge Type and Intent to Discharge (If Applicable) to the chart review form that is given to the staff to monitor form completion. This form will be given to the Clinical Supervisor to review during monthly supervision.
a. Responsible party ?Clinical
supervisor
Completion date 11/1/2022
3.Clinical Supervisor will review all Administrative Discharges as they occur to ensure compliance.
a. Responsible party ?Clinical
Supervisor
Completion date 11/1/2022 |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in two of two applicable client records reviewed.
Client # 5 was admitted on January 31, 2022 and was administratively discharged on March 28, 2022. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.
Client # 6 was admitted on February 11, 2022 and was administratively discharged on February 26, 2022. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Clinical Supervisor will retrain the staff on the protocol in carrying out an Administrative Discharge i.e., giving client opportunity to request reconsideration of the facility's decision to terminate treatment. All staff will receive the written policy and will sign the attendance sheet verifying that they were trained in the correct protocol.
a. Responsible party ?Clinical
supervisor
Completion date 11/1/2022
2. Clinical Supervisor will add Discharge Type and Intent to Discharge (If Applicable) to the chart review form that is given to the staff to monitor form completion. This form will be given to the Clinical Supervisor to review during monthly supervision.
a. Responsible party ?Clinical
supervisor
Completion date 11/1/2022
3.Clinical Supervisor will review all Administrative Discharges as they occur to ensure compliance.
a. Responsible party ?Clinical
Supervisor
Completion date 11/1/2022 |
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 a complete client record, which is to include a discharge summary, in two of four applicable client records reviewed.
Client # 5 was admitted on January 31, 2022 and was administratively discharged on March 28, 2022. There was no discharge summary documented in the record as of the date of the inspection.
Client # 6 was admitted on February 11, 2022 and was administratively discharged on February 26, 2022. There was no discharge summary documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
*Clinical Supervisor will provide in-service training on completing discharge summary upon administrative discharge of a participants to counselors.
*Clinical Supervisors will conduct Random monitor of three (3) charts per clinician per month to validate that discharge summary forms are completed correctly
Responsible Party: Clinical Supervisor Completion Date 11/1/2022
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