INITIAL COMMENTS
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This report is a result of an on-site renewal inspection and complaint investigation conducted on October 19, 2020 through October 23, 2020 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the renewal inspection and on-site complaint investigation, Libertae Family House Libertae Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of administrative paperwork on October 30, 2020, the facility failed to document the procedures for the facility's annual evaluations.
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Plan of Correction
The deficiency shall be corrected by taking the following action steps:
1. The project director in collaboration with the management team, will complete an assessment of staff training needs for the current year. The assessment will include questionnaires completed by all staff to identify needs.
2. The data will be compiled and summarized.
3. An overall formal plan for addressing these needs will be developed.
4. Trainings that have been identified will be held.
5. Every training module will include a feedback form that shall be submitted to the project's administrative assistant in order to receive a certificate of completion for the training session.
6. The administrative assistant shall submit these to the project director quarterly, who will
7. review and assess the trainings.
The deficiency shall be corrected by 12/31/2020 |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of personnel records and training documents on October 19, 2020 through October 23, 2020, the facility failed to document needs assessments in personnel records, #10, 11, 12, 13 and 14.Employee #10 was hired 7/17/14Employee #11 was hired 9/15/98Employee #12 was hired 5/5/14Employee #13 was hired 2/13/19Employee #14 was hired 9/17/18Findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency shall be corrected by taking the following action steps:
1. The administrative assistant will distribute a training needs questionnaire to the respective employees by 12/4/2020, for return by 12/11/2020.
2. The training needs will be reviewed by each employee's supervisor, and
3. Documented in the employee's personnel record.
In order to ensure that the deficiency does not reoccur, the Administrative Assistant is responsible to maintain documentation of all staff training needs assessments and training documents in employee personnel records and within the required time frames.
Oversight of the personnel records is the responsibility of the Finance Director, who supervises the Administrative Assistant of the project. by 12/18/2020. The Finance Director shall review all personnel files on a quarterly basis for completeness of documentation.
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of personnel records and training documents on October 19, 2020 through October 23, 2020, the facility failed the date of completion for the overall training plan as documented in their P&P. Their P&P states that the overall training plan will be completed by May Annually. Findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency shall be corrected by the Facility Director, who will review and update the overall training plan for the year by 12/31/2020.
In order to ensure that the deficiency does not reoccur, it is the responsibility of the administrative assistant to set a calendar reminder for the annual review of the project's annual training plan to begin on May 1, 2021. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of personnel records and training documents on October 19, 2020 through October 23, 2020, the facility failed the date of completion for the annual evaluation as documented in their P&P. Findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director will conduct an annual evaluation of the overall training plan. The evaluation shall determine the extent to which the plan addressed the identified needs, including a determination of the extent to which implementing the plan eliminated or satisfied the identified needs. Data collected on Staff Training and Course Evaluation Forms after each training will be submitted to the administrative assistant who will tally results of each training and furnish to the project director for monthly review. A final assessment will be made in May 2021 when questionnaires are completed by all staff, which will include individual evaluations of the preceding trainings and suggestions for upcoming trainings. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records and training documents on October 19, 2020 through October 23, 2020, the facility failed to document individual training plans for training year July 1, 2020 through June 30, 2021 in personnel records, #6, 10, 11, 12, 13 and 14.Employee #6 was hired 5/14/15Employee #10 was hired 7/17/14Employee #11 was hired 9/15/98Employee #12 was hired 5/5/14Employee #13 was hired 2/13/19Employee #14 was hired 9/17/18Findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Correction of Deficiency will be achieved by December 31, 2020.
The administrative assistant of the project shall notify and distribute to supervisors the trainings required of all personnel.
The supervisory staff shall conduct a supervision session with each employee by December 28, 2020, in order to develop a training plan.
The supervisory staff in conjunction with the administrative assistant are responsible for completing and entering the training plan in the personnel file of each employee by December 31, 2020. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and training documents on October 19, 2020 through October 23, 2020, the facility failed to document the required HIV/AIDS and or TB/STD within the required time period in personnel records, #10, 11, 12 and 14.Employee #10 was hired 7/17/14 (Treatment Tech.)HIV/AIDS not documentedEmployee #11 was hired 9/15/98 (Dir. of Social Services)TB/STD not documentedEmployee #12 was hired 5/5/14 (Treatment Tech.)HIV/AIDS not documentedEmployee #14 was hired 9/17/18 (Treatment Tech.)Reviewed Personnel record/training did not show documentation that the HIV/AIDS and TB/STD training was completed, but on the SRFSR it states that HIV/AIDS was completed on 6/13/19 and TB/STD was completed on 12/1/19. Could not verify that they were completed. Findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Correction of Deficiency will be achieved by March 30, 2021.
Personnel who have not met training requirements shall register to attend.
Personnel who have completed trainings shall submit documentation to the program to be filed in personnel records.
In order to ensure that the deficiency does not reoccur, the Administrative Assistant is responsible to monitor the compliance of all staff with attendance at mandatory communicable disease training within the required time frames.
Oversight of the staff development program is the responsibility of the supervisor of the Administrative Assistant of the project. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
A physical plant inspection was conducted on October 19, 2020. The following deficiencies were identified during this inspection:The glass light fixture located in the main hallway was brokenThe ceiling tiles were stained from what looked like water damageThese findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. The light fixture in the hallway was replaced. The ceiling tiles in the hallway were replaced.
The correction will be maintained by taking the following action steps:
1. The Facility Director will disseminate the Building and Grounds Policy and Procedures and review procedures with operations department personnel, to include the need to keep all exit lights lit at all times.
2. All staff will be directed to enter a work order in the facility management system should they identify any area of the buildings and grounds that need attention, including findings of exit lights not working.
3. It is the responsibility of maintenance personnel to respond to all work orders in the facilities management system in a timely manner.
4. All grounds of the facility will be inspected monthly by maintenance personnel who are to ensure that all exit lights are functional and lit.
5. The Director of Operations or the Facility Director shall review with maintenance personnel all work orders entered into the facility management system and the resolution of same on a monthly basis.
6. The management team of the facility will develop and implement written standard work procedures for maintenance services that are organized to include all areas for improvement that have been identified by this inspection.
7. The Facility Director will generate and disseminate data reports that demonstrate improvements in the area of fire safety. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
A physical plant inspection was conducted on October 19, 2020. The following deficiencies were identified during this inspection:There were two dumpsters located near the rear door of the kitchen area, one was found to be uncovered. and the other was pushed against the wall and the cover couldn't be closed. Additionally, garbage was found on the ground around both dumpsters. These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The deficiency has been corrected. The dumpster has been relocated so that the cover can be closed. All garbage has been picked up and discarded.
The correction will be maintained by taking the following action steps:
1. The Facility Director will disseminate the Building and Grounds Policy and Procedures and review procedures with operations department personnel, to include the need to keep all trash and garbage receptacles closed, and to immediately report any issues that would prevent the closure of a trash receptacle.
2. All staff will be directed to enter a work order in the facility management system should they identify any area of the buildings and grounds that need attention, including findings of garbage on the ground around the dumpsters.
3. It is the responsibility of maintenance personnel to respond to all work orders in the facilities management system in a timely manner.
4. All grounds of the facility will be inspected monthly by maintenance personnel who are to ensure that dumpster lids can be closed and that there is no garbage on the ground around them.
5. The Director of Operations or the Facility Director shall review with maintenance personnel all work orders entered into the facility management system and the resolution of same on a monthly basis.
6. The management team of the facility will develop and implement written standard work procedures for maintenance services that are organized to include all areas for improvement that have been identified by this inspection.
7. The Facility Director will generate and disseminate data reports that demonstrate improvements in the area of dietetic services.
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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
A physical plant inspection was conducted on October 19, 2020. The following deficiencies were identified during this inspection:The couches and chairs located in the lounge area were busted and torn.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. All furnishings in residents' lounge areas have been inspected. Items have been discarded. Others have been identified as needing refurbishing. This work has entered into the maintenance log for attention.
The correction will be maintained by taking the following action steps:
1. The Facility Director will disseminate the Building and Grounds Policy and Procedures and review procedures with operations department personnel, to include identification and reporting of furnishings in need of repair or removal.
The corrective action will be maintained by the following:
1. Whenever it comes to the attention of any staff member that any furnishings are in disrepair, a work order is to be entered into the facilities management system for timely attention by maintenance personnel.
2. All furnishings in clients' common living areas will be inspected monthly by maintenance personnel who are to ensure that all furnishings are in good working order and identify any furnishings that need removal, repair or replacement.
2. The Director of Operations or the Facility Director shall review with maintenance personnel all furniture inventory reports and develop an interim plan for common area use, when necessary and a timeline for the repair or replacement of identified furniture.
3. The management team of the facility will develop and implement written standard work procedures for maintenance services that are organized to include all areas for improvement that have been identified by this inspection. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
A physical plant inspection was conducted on October 19, 2020. The following deficiencies were identified during this inspection:Two staff refrigerators, one found in the cooking area and the other located in the dinning hall, did not have thermometers.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected.
The correction will be maintained by taking the following action steps:
1. The Facility Director will revise and disseminate the Dietetic Services Policy and Procedures to include language regarding the receiving, storing and preserving of food that indicating that all refrigerators in use, including those used by staff, are to have thermometers.
2. A checklist will be placed outside of all refrigerators, including those used by staff, to be initialed by cleaning staff each week, once the refrigerator has been inspected and cleaned. If the thermometer is missing, this will be notated.
3. The food service staff and clients will be oriented to the revised Dietetic Services Policy and Procedures.
The corrective action will be maintained by the following:
1. All facility refrigerators will be inspected weekly by the Food Services Coordinator, who is to check for the presence or absence of thermometers.
2. The Director of Operations or the Facility Director shall conduct a monthly walk through of the food storage areas, including all refrigerators, even those used by staff, to detect and note any further deficiencies.
3. The management team of the facility will develop and implement written standard work procedures for dietetic services that are organized to include all areas for improvement that have been identified by this inspection.
4. The Facility Director will generate and disseminate data reports that demonstrate improvements in the area of dietetic services. |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
A physical plant inspection was conducted on October 19, 2020. The following deficiencies were identified during this inspection:Cases of food were store on the floor in another storage room, other than the dry storage closet, in the basement.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. All food items have been moved out of the basement into the dry storage area in the kitchen area.
The correction will be maintained by taking the following action steps:
1. The Facility Director will revise and disseminate the Dietetic Services Policy and Procedures to include language regarding the receiving, storing and preserving of food that indicating that food is not to be stored outside of the kitchen areas, nor on the floor.
3. The food service staff and clients will be oriented to the revised Dietetic Services Policy and Procedures.
The corrective action will be maintained by the following:
1. All food storage areas will be inspected and inventoried weekly by the Food Services Coordinator, who is to ensure that food items are in required storage areas.
2. The Director of Operations or the Facility Director shall conduct a monthly walk through of the food storage areas, to detect and note any further deficiencies.
3. The management team of the facility will develop and implement written standard work procedures for dietetic services that are organized to include all areas for improvement that have been identified by this inspection.
4. The Facility Director will generate and disseminate data reports that demonstrate improvements in the area of dietetic services. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records on October 19, 2020 through October 23, 2020, the facility failed to document within 7 days after hire the required training in records, #3, 5, 7 and 8.Employee # 3 was hired 10/13/20 - documentation of training was reviewed, but no date when the training was completed.Employee # 5 was hired 10/15/20 - training not documentedEmployee #7 was hired 10/13/20 - training not documentedEmployee # 8 was hired 9/22/20 - Training not documentedFinding reviewed with facility staff during the licensing inspection.
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Plan of Correction
This deficiency has been corrected. All staff, including new hires, have been instructed in the use of the fire extinguishers and the required training has been documented in their personnel files.
The corrective action will be maintained by the facility, by following the standard work procedures which were developed and implemented for personnel hiring. This includes the orientation of new staff to the use of the fire extinguishers by the operations personnel, who then signs off on the training form and returns it to the office manager for inclusion in the staff's personnel file.
It is the responsibility of the Finance Director, to then review the personnel files quarterly for completeness. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill record on October 19, 2020, the facility failed to document fire drills monthly. Fire drill record reviewed from August 2019 through October 2020.The facility failed to conduct fire drills during the months of:June 2020July 2020August 2020September 2020The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
So that all employees, visitors, and clients of Libertae know what to do in the event of a fire, Libertae conducts unannounced fire drill practices according to a schedule only aware to the Assistant Operations Manager, who maintains a record of the fire drill practices.
It is the responsibility of the Director of Operations to oversee all Fire/Emergency Building Evacuation plans and procedures and to review them periodically to monitor the agency's performance regarding safety and emergency preparedness.
The deficiency has been corrected. The fire drill protocol was reviewed with operations staff. Unannounced fire drills have been scheduled and will be held monthly.
The Quality Assurance Committee will review the findings of all fire drill reports on a monthly basis. Any deficiencies discovered will be addressed by in-service training of staff.
New staff are trained in facilitating fire drills upon hiring and orientation.
Fire drill logs will be available for inspection. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records on October 19, 2020 through October 23, 2020, the facility failed to document within 7 days after hire the required training in records, #1, 2, 5, 7 and 8.Employee #1 was hired 8/24/20 - training not documentedEmployee #2 was hired 8/10/20 - training not documentedEmployee # 5 was hired 10/15/20 - training not documentedEmployee #7 was hired 10/13/20 - training not documentedEmployee # 8 was hired 9/22/20 - Training not documentedFindings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This deficiency has been corrected. All staff, including new hires, have been instructed to perform assigned tasks during emergencies, and the required training has been documented in their personnel files.
The corrective action will be maintained by the facility, by following the standard work procedures which were developed and implemented for personnel hiring.
This includes the orientation of new staff to performing assigned tasks during emergencies by the operations personnel, who then signs off on the training form and returns it to the office manager for inclusion in the staff's personnel file.
It is the responsibility of the Finance Director, to then review the personnel files quarterly for completeness. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's fire drill record on October 19, 2020, the facility failed to document overnight fire drills every 6 months. Fire drill record reviewed from August 2019 through October 2020.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
So that all employees, visitors, and clients of Libertae know what to do in the event of a fire, Libertae conducts unannounced fire drill practices according to a schedule only aware to the Assistant Operations Manager, who maintains a record of the fire drill practices.
It is the responsibility of the Director of Operations to oversee all Fire/Emergency Building Evacuation plans and procedures and to review them periodically to monitor the agency's performance regarding safety and emergency preparedness.
The deficiency has been corrected. The fire drill protocol was reviewed with operations staff. Unannounced fire drills have been scheduled and will be held during sleeping hours in the upcoming quarters.
The Quality Assurance Committee will review the findings of all fire drill reports on a monthly basis.
Any deficiencies discovered will be addressed by in-service training of staff. New staff are trained in facilitating fire drills upon hiring and orientation. Fire drill logs will be available for inspection. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's fire drill record on October 19, 2020, the facility failed to document the exit route during the 8/13/19 fire drill and October 2020 (no date when it was completed) fire drill. Fire drill record reviewed from August 2019 through October 2020.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
So that all employees, visitors, and clients of Libertae know what to do in the event of a fire, Libertae conducts unannounced fire drill practices according to a schedule only aware to the Assistant Operations Manager, who maintains a record of the fire drill practices.
It is the responsibility of the Director of Operations to oversee all Fire/Emergency Building Evacuation plans and procedures and to review them periodically to monitor the agency's performance regarding safety and emergency preparedness.
The deficiency has been corrected. The fire drill protocol was reviewed with operations staff. The facility has prepared alternate exit routes to be used during fire drills.
The Quality Assurance Committee will review the findings of all fire drill reports on a monthly basis.
Any deficiencies discovered will be addressed by in-service training of staff. New staff are trained in facilitating fire drills upon hiring and orientation. Fire drill logs will be available for inspection.
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705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of the facility's fire drill record on October 19, 2020, the facility failed to document AM/PM on the fire drills monthly. Fire drill record reviewed from August 2019 through October 2020.The following months:November 2019December 2019January 2020March 2020The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
So that all employees, visitors, and clients of Libertae know what to do in the event of a fire, Libertae conducts unannounced fire drill practices according to a schedule only aware to the Assistant Operations Manager, who maintains a record of the fire drill practices.
It is the responsibility of the Director of Operations to oversee all Fire/Emergency Building Evacuation plans and procedures and to review them periodically to monitor the agency's performance regarding safety and emergency preparedness.
The deficiency has been corrected. The fire drill protocol was reviewed with operations staff. The facility has prepared a fire drill schedule that includes different days of the week, different times and different shifts. Staff shall document whether the fire drill took place during the AM or PM hours.
The Quality Assurance Committee will review the findings of all fire drill reports on a monthly basis.
Any deficiencies discovered will be addressed by in-service training of staff. New staff are trained in facilitating fire drills upon hiring and orientation. Fire drill logs will be available for inspection.
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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's fire drill record on October 19, 2020, the facility failed to document that the fire alarm was operative or not during the October 2020 fire drill. Fire drill record reviewed from August 2019 through October 2020.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency shall be corrected by taking the following action steps:
1. The Facility Director will disseminate the Building and Grounds Policy and Procedures and review procedures with operations department personnel, to include the need to repair inoperable smoke detectors and/or fire alarms within 48 hours of the time a smoke detector or fire alarm is found to be inoperative, and to document that repair in the fire drill record.
2. All staff will be directed to enter a work order in the facility management system should they identify any area of the buildings and grounds that need attention, including findings of smoke detectors and/or fire alarms found to be inoperative. This finding will be triaged as urgent and in need of immediate repair, within 48 hours.
3. It is the responsibility of maintenance personnel to respond to all work orders in the facilities management system in a timely manner, in the case of smoke detectors and/or fire alarms, within 48 hours.
4. All grounds of the facility will be inspected monthly by maintenance personnel who are to ensure that all smoke detectors and fire alarms are operable.
5. The Director of Operations or the Facility Director shall review with maintenance personnel all work orders entered into the facility management system and the resolution of same on a monthly basis.
6. The management team of the facility will develop and implement written standard work procedures for maintenance services that are organized to include all areas for improvement that have been identified by this inspection.
7. The Facility Director will generate and disseminate data reports that demonstrate improvements in the area of fire safety. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(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.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
Based on a conversation with the Project Director/Facility Director on October 19,2020, the facility failed to notify DDAP that they moved one license into this license facility. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency has been corrected. The facility submitted a request to DDAP on 10/22/2020, for approval to move out of one licensed facility into the other. The request was denied.
The facility that was closed, due to operational considerations that arose from COVID, is being re-opened. It has been disinfected and sanitized, furnishings in disrepair have been discarded. Rooms are being re-painted and bedrooms are being reconfigured to accommodate less clients as a precaution to reduce the likelihood of COVID exposure.
The clients will be moved back by or before 12/11/2020. |
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 from October 19, 2020 through October 23, 2020, the facility failed to obtain informed and voluntary consent to release in client records, #1, 3, 4, 6 and 7. Client #1 was admitted on August 2, 2019 and discharged on January 31, 2020. Client #3 was admitted October 11, 2019 and discharged May 26, 2020. Client #4 was admitted June 14, 2019 and is still receiving treatment services. Client #6 was admitted October 21, 2019 and is still receiving treatment services. Client #7 was admitted April 30, 2020 and is still receiving treatment services. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency will be corrected by reviewing any consent form to disclose information for each of the elements below. If the form is missing even one of the elements, it shall not be considered a valid consent. Therefore, the information shall not be released.
Every consent to disclose shall be signed and dated by the client. The form shall specify the exact purpose of the disclosure.
The facility is required to adhere to the Rule (Title 42 CFR Part 2 ? Confidentiality of Alcohol and Drug Abuse Patient Records). In order for the facility to disclose any information about a client, the client must authorize the disclosure by signing a valid consent form. The consent form must contain all of the following nine elements to be valid:
1. The name of the client.
2. The name of the program making the disclosure.
3. The recipient of the information (which should not be as general as an entire agency or department, but may describe the recipient's job title and/or job functions).
4. The purpose of the disclosure, which should be narrowly described and should correspond with the information to be released.
5. The information to be released, described as exactly and narrowly as possible.
6. That the client understand the consent maybe revoked at any time, orally or in writing.
7. The date or condition upon which the consent expires, if it has not been revoked earlier.
8. The date the consent form is signed.
9. The signature of the client.
A client should never sign or be requested to sign a consent form before all of the blanks have been filled in. Copies of all consent forms shall be kept in the client's file. Clients will be offered a copy of all consent forms and an acknowledgement of same will be on every consent form.
The Project Director will review the Confidentiality Policies and Procedures with all treatment staff by December 13, 2020.
The Project Director, with the Quality Assurance Committee, will review 100% of the records of new admissions on a monthly basis, to verify and report any problems to the supervisors of responsible staff for correction.
The effectiveness of these measures will be evaluated by the Quality Assurance Committee at each meeting and modified as necessary. |
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 on October 19, 2020 through October 23, 2020, the facility failed to show that the client was offered a copy of the release of information form in records, #8 and 9.Client #8 - consent to release dated 11/15/19 for a Karen I. Client #9 - consent to release dated 1/30/20 to probation and parole. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiency will be corrected by reviewing any consent form to disclose information for each of the elements below. If the form is missing even one of the elements, it shall not be considered a valid consent. Therefore, the information shall not be released.
Every consent to disclose shall be signed and dated by the client. The form shall specify the exact purpose of the disclosure.
The facility is required to adhere to the Rule (Title 42 CFR Part 2 ? Confidentiality of Alcohol and Drug Abuse Patient Records). In order for the facility to disclose any information about a client, the client must authorize the disclosure by signing a valid consent form. The consent form must contain all of the following nine elements to be valid:
1. The name of the client.
2. The name of the program making the disclosure.
3. The recipient of the information (which should not be as general as an entire agency or department, but may describe the recipient's job title and/or job functions).
4. The purpose of the disclosure, which should be narrowly described and should correspond with the information to be released.
5. The information to be released, described as exactly and narrowly as possible.
6. That the client understand the consent maybe revoked at any time, orally or in writing.
7. The date or condition upon which the consent expires, if it has not been revoked earlier.
8. The date the consent form is signed.
9. The signature of the client.
A client should never sign or be requested to sign a consent form before all of the blanks have been filled in. Copies of all consent forms shall be kept in the client's file. Clients will be offered a copy of all consent forms and an acknowledgement of same will be on every consent form.
The Project Director will review the Confidentiality Policies and Procedures with all treatment staff by December 13, 2020.
The Project Director, with the Quality Assurance Committee, will review 100% of the records of new admissions on a monthly basis, to verify and report any problems to the supervisors of responsible staff for correction.
The effectiveness of these measures will be evaluated by the Quality Assurance Committee at each meeting and modified as necessary. |
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 on October 19, 2020 through October 23, 2020, the facility failed to documentation that client rights were reviewed or explained to the clients.Client #1 was admitted on August 2, 2019 and was discharged on January 31, 2020. Client #2 was admitted October 29, 2019 and discharged March 19, 2020. Client #3 was admitted October 11, 2019 and discharged May 26, 2020. Client #4 was admitted June 14, 2019 and still an active client. Client #5 was admitted July 6, 2018 and still an active client. Client #6 was admitted October 21, 2019 andstill an active client. Client #7 was admitted April 30, 2020 and still an active client. Client #10 was admitted on June 29, 2020 and still an active client. Client #11 was admitted on June 29, 2020 and still an active client. The findings were review with facility staff during the licensing inspection.
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Plan of Correction
The deficiency will be corrected by taking the following action steps:
1. The facility director, with the manager of admissions, will review, revise and update the intake and admissions policies and procedures as needed.
2. The facility director, with the manager of admissions will develop and implement written standard work procedures for admissions that include the documentation in the clinical records of written acknowledgement that each client was notified of her rights.
3. The manager of admissions will ensure that a written acknowledgement that the client has been notified of her rights has been obtained from all clients upon admission and filed in each client's record.
The correction will be maintained by conducting a rigorous review of client records to ensure that the client's acknowledgment of notification of her rights has been obtained and included in the client record.
It is the responsibility of the Facility Director with the Director of Social Services and Finance Director to conduct a review of all client records every 30 days for all clients admitted the previous 30 days, to verify that each client record captures the required documentation, including this acknowledgement. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a complaint investigation that took place October 19, 2020 through October 23, 2020, the facility failed to ensure that all required staff who handles medication took the medication assistance procedures training. Based on a review of personnel records and interviews with facility staff, only 2 of the 7 Technicians had this training.
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Plan of Correction
This deficiency has been corrected. All required staff who handle medication have taken the medication assistance procedures training. A record of the completed training is on file in each staff's personnel record.
The corrective action will be maintained by the facility, by following the standard procedures which were developed and implemented for personnel hiring. This includes the orientation of new staff to medication procedures by the staff nurse, who then signs off on the training form and returns it to the office manager for inclusion in the staff's personnel file.
It is the responsibility of the Finance Director, who to review the personnel files quarterly for completeness. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of unusual incidents on October 19, 2020 through October 23, 2020, the facility failed to report to DDAP 4 unusual incidents with 3 business days following the unusual incident.Unusual incidents:10/18/19 - fire personnel onsite - DDAP notified on 11/14/19 (late)10/6/19 - ambulance personnel onsite10/2/19 - ambulace personnel onsite7/26/19 - police personnel onsite The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project shall file a written unusual incident report with the Department of Licensing within 3 business days following any event at the facility that required the presence of fire personnel, ambulance to transport clients to healthcare facilities.
The deficiency shall be corrected by taking the following action steps:
1. The Facility Director, with the Manager of Admissions and treatment tech coordinator, shall review the policy and procedures regarding reporting of unusual incidents.
2. The Treatment Tech Team Coordinator will monitor the facility incident log of the project and alert the Manager of Admissions of the need for reporting compliance.
3. The Manager of Admissions, or her designee, shall complete and submit all facility incident reports within the required timeframe on the web-based system, or via fax or email to the Accountability and Program Improvement Division of the Department of Licensing.
4. The Manager of Admissions shall maintain a log of incident reports that have been filed, and produce it for inspection.
5. A review of facility incidents and concomitant mandated reports shall be a part of the standard work of the Quality Assurance Committee and reviewed at monthly management team meetings. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records on October 19, 2020 through October 23, 2020 the facility failed to complete documentation of a physical examinations in records, 8, 9, 10, 12, 13 and 14.Client #8 was admitted on February 12, 2020 and discharged on April 6, 2020. Client #9 was admitted on February 13, 2020 and discharged on September 23, 2020 . Client #10 was admitted on June 29, 2020 and still an active client. Client #12 was admitted on August 21, 2020 and still an active client. Client #13 was admitted on December 17, 2019 and discharged June 11, 2020. Client #14 was admitted on January 6, 2020 and discharged on May 14 , 2020 . These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
The deficiency will be corrected by taking the following action steps:
1. The facility director, with the manager of admissions, will review, revise and update the intake and admissions policies and procedures as needed.
2. The facility director, with the manager of admissions will develop and implement written standard work procedures for admissions that include the documentation in the clinical records of a physical examination for each client within 7 days of admission.
3. The manager of admissions will ensure that documentation of a physical examination has been obtained for all clients within 7 days of admission and filed in each client's record.
The correction will be maintained by conducting a rigorous review of client records to ensure that the documentation of a physical examination is included in each client's record within 7 days of admission.
It is the responsibility of the Facility Director with the Director of Social Services and Finance Director to conduct a review of all client records every 30 days for all clients admitted the previous 30 days, to verify that each client record captures the required documentation, including this documentation of a physical examination. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client records from October 19, 2020 through October 23, 2020, The facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client. Client #10 was admitted on June 29, 2020 and still in treatment. The comprehensive treatment plan was completed on August 12, 2020, the client did not sign the plan. Client #11 was admitted on June 29, 2020 and still in treatment. The comprehensive treatment plan was completed on September 9, 2020, the client did not sign the plan. Client #12 was admitted on July 21, 2020 and still in treatment. The comprehensive treatment plan was completed on September 8, 2020, the client did not sign the plan. Client # 13 was admitted into treatment on December 17, 2019 and discharged on June 11, 2020. The comprehensive treatment plan was completed on March 24, 2020, the client did not sign the plan. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The treatment provider shall begin to formulate a preliminary treatment and rehabilitation plan upon intake and assessment. At this time a history is taken and psychosocial evaluation is provided. Documentation of the finalized individual treatment and rehabilitation plan that has been developed in collaboration with the client is to be included in the client record within the required timeframe. The treatment plan shall be signed and dated by the individual rendering services. It shall also be documented that the treatment plan was developed with the client.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, plus 100% of new admissions per month of the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported and reviewed by the Project Director for corrective action. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records from October 19, 2020, through October 23, 2020. The facility failed to ensure that an individual treatment and rehabilitation plan was developed with the proposed type of support service.Client #10 was admitted on June 29, 2020, and still in treatment. The comprehensive treatment plan dated August 12, 2020, had no proposed type of support service.Client #11 was admitted on June 29, 2020, and still in treatment. the comprehensive treatment plan dated September 9, 2020, had no proposed type of support service.Client #12 was admitted on July 21, 2020, and still in treatment. The comprehensive treatment plan dated September 8, 2020, had no proposed type of support service.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The treatment provider shall begin to formulate a preliminary treatment and rehabilitation plan upon intake and assessment. At this time a history is taken and psychosocial evaluation is provided. Documentation of the finalized individual treatment and rehabilitation plan that has been developed in collaboration with the client is to be included in the client record within the required timeframe. The treatment plan shall include written documentation of the proposed types of support services.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, plus 100% of new admissions per month of the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported and reviewed by the Project Director for corrective action. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records from October 19, 2020 through October 23, 2020. The facility failed to document the provision of a treatment plan update at least every 30 days for client records #10,11,12, and 13. Client #10 was admitted on June 29, 2020 and still in treatment. The treatment plan update documentation was not found in the record.. Client #11 was admitted on June 29, 2020 and still in treatment. The comprehensive treatment plan was developed on September 9, 2020 and the treatment plan update was developled on October 19, 2020. Client #12 was admitted on July 21, 2020 and still in treatment. The comprehensive treatment plan was developed on September 8, 2020 and the treatment plan update documentation was not found in the record. Client # 13 was admitted on December 17, 2019 and was discharged on June 11, 2020 and the treatment plan update documentation was not found in the record. These findings were reviewed with facility staff during the licensing process. The treatment plan up- date documentation was not found in the record.
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Plan of Correction
Treatment and rehabilitation plans shall be reviewed and updated at least every thirty days. The treatment plan update shall include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, per month of the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported and reviewed by the Project Director for corrective action. |
709.53(a)(1) LICENSURE Consent Forms
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:
(1) Consent forms.
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Observations
Based on a review of client records on October 19, 2020, through October 23, 2020, the facility failed to completion documentaion of consent to release forms in two client records.Client #10 was admitted on June 29, 2020, and still an active client.Client #11 was admitted on June 29, 2020, and still an active client.The findings were review with facility staff during the licensing inspection.
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Plan of Correction
The deficiency will be corrected by taking the following action steps:
1. The facility director, with the manager of admissions, will review, revise and update the intake and admissions policies and procedures as needed.
2. The facility director, with the manager of admissions will develop and implement written standard work procedures for admissions that include obtaining signed consents to treatment upon admission.
3. The manager of admissions will ensure that a signed consent to treatment has been obtained from all clients upon admission.
The correction will be maintained by conducting a rigorous review of client records to ensure that the client's consent to treatment has obtained and included in the client record.
It is the responsibility of the Facility Director with the Director of Social Services and Finance Director to conduct a review of all client records every 30 days for all clients admitted the previous 30 days, to verify that each client record captures the required documentation, including the consent to treatment. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records from October 19, 2020 through October 23, 2020, The facility failed to document timely progress notes in 7 client records. Client #1 was admitted on August 2, 2019 and was discharged on January 31, 2020. Documentation in the client's record indicated the last session was completed on 12/17/19.Client #3 was admitted October 11, 2019 and discharged May 26, 2020. Documentation in the client's record indicated the last session was on 3/20/20.Client #4 was admitted June 14, 2019 and is still receiving treatment. Documentation in the client's record indicated the last session was completed on 9/25/20.Client #5 was admitted July 6, 2018 and is still receiving Treatment. Documentation in the client's record indicated the last session was on 10/1/20.Client #6 was admitted October 21, 2019 and is still receiving Treatment. Documentation in the client's record indicated the last session was on 8/20/20.Client #7 was admitted April 30, 2020 and is still receiving treatment. Documentation in the client's electronic record indicated the last session was completed on 9/3/20.The findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
There shall be a progress note after each significant client contact which shall be dated and signed by the individual making the entry.
Progress notes shall include data, assessment and plans relative to treatment.
The data shall include information presented by the client during the counseling session, counselor observations and information about the client from other sources.
The assessment is the interpretative statement(s) based upon both new and previous information and includes the counselor's analysis of and conclusions regarding the client's current situation or status.
The plan, or strategies, shall reflect the counselor's actions to be taken in light of the evaluation and indicate the direction of treatment and include action steps, counselor plan(s) and client assignments or tasks.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Project Director will review the policy and procedures with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records.
Adherence to the requirements regarding client records will be verified and any problems will be reported to the Project Director for corrective action. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of seven client records on October 19, 2020 through October 23, 2020, the facility failed to document follow-ups for records, #8, 9 and 13. Per the facility's policy and procedure follow-ups are to be conducted within 7 days of the client's discharge dateClient #8 was admitted on February 12, 2020 and discharged on April 6, 2020. No follow up documented.Client #9 was admitted on February 13, 2020 and discharged on September 23, 2020. No follow up documented.Client #13 was admitted on December 17, 2019 and discharged June 11, 2020. No follow up documented.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The client record shall contain follow-up information. When a client has been discharged the project shall, with the written consent of the client and within one week from the day the the client has discharged, attempt to contact the client to determine her disposition at one-week post-discharge. Once the attempt has been made and documented, the project shall consider its obligation to the individual fulfilled.
Staff who render treatment services are required to adhere to the program's policy and procedures regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the clinical supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records and 100% of discharged clients for the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported by the Project Director for corrective action. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records from October 19, 2020 through October 23, 2020, the facility failed to document work therapy in client records, #8, 9, 10, 11, 12 and 13. Each client is assigned chores throughout the facility.Client #8 was admitted on February 12, 2020. Client #9 was admitted on February 13, 2020. Client #10 was admitted on June 29, 2020.Client #11 was admitted on June 29, 2020.Client #12 was admitted on August 21, 2020. Client #13 was admitted on December 17, 2019. The findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
he deficiency will be corrected by taking the following action steps:
1. The facility director will develop, implement and disseminate a written policy that addresses clients' involvement in the project as it pertains to work as therapy.
2. The facility director will revise the clients' handbook to include language indicating that work done by the client at the project is an integral part of her treatment and rehabilitation plan.
3. The facility director with the manager of admissions will review, revise and update intake and admissions procedures to ensure that
(a) program descriptions provided prior to admission include language regarding work done by client as part of her treatment and rehabilitation plan
(b) specific acknowledgement is obtained upon admission that client has been advised that work done at the project is an integral part of her treatment and rehabilitation plan
(c) client acknowledgement that she has been oriented to the program includes language that she will be assigned weekly chores and that this is an integral part of her treatment and rehabilitation plan
4. The Facility Director will review and revise the format of the treatment and rehabilitation plan to include the documentation that weekly chore assignments are a part of the plan. Treatment team will be oriented to the revised format.
The correction will be maintained by conducting a rigorous review of client records to ensure that client acknowledgements have been obtained work therapy is documented as required.
It is the responsibility of the Facility Director with the Director of Social Services and Finance Director to conduct a review of all client records every 30 days for all clients admitted the previous 30 days, to verify that each client record captures the required documentation. |
709.54(a)(2) LICENSURE Receiving/storing/preserving
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(2) Receiving, storing and preserving of food stuff.
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Observations
A physical plant inspection was conducted on October 19, 2020. The following deficiencies were identified during this inspection:There were multiple expired dates of stored food items in the personal refrigerator in the kitchen: identified was two jars of Sysco Reliance Heavy Duty Mayonnaise. One jar was dated use by 2004 and the 2nd jar was dated use by 2009.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency will be corrected by taking the following action steps:
1. The Facility Director will revise and disseminate the Dietetic Services Policy and Procedures to include language regarding the receiving, storing and preserving of food that indicates when inspections of food storage are to occur and the requirement that expired food items are not to be used, but to be discarded at the "use by" date.
2. The food service staff and clients will be oriented to the revised Dietetic Services Policy and Procedures.
The corrective action will be maintained by the following:
1. A weekly inventory of all food items is to be done by the Food Services Coordinator, who is to discard food items who have reached the "use by" date.
2. The Director of Operations or the Facility Director shall conduct a monthly walk through of the food storage areas to detect and note any further deficiencies.
3. The management team of the facility will develop and implement written standard work procedures for dietetic services that are organized to include all areas for improvement that have been identified by this inspection.
4. The Facility Director will generate and disseminate data reports that demonstrate improvements in the area of dietetic services.
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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 seven client records on October 19, 2020 through October 23, 2020. The facility failed to document that clients received an orientation in records, #1, 2, 3, 4, 5, 6 and 7.Client #1 was admitted on August 2, 2019 and was discharged on January 31, 2020. Client #2 was admitted October 29, 2019 and discharged March 19, 2020. Client #3 was admitted October 11, 2019 and discharged May 26, 2020. Client #4 was admitted June 14, 2019 and is still receiving Treatment. .Client #5 was admitted July 6, 2018 and is still receiving Treatment. Client #6 was admitted October 21, 2019 and is still receiving treatment. Client #7 was admitted April 30, 2020 and is still receiving treatment. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency will be corrected by taking the following action steps:
1. The facility director, with the manager of admissions, will review, revise and update the intake and admissions policies and procedures as needed.
2. The facility director, with the manager of admissions will develop and implement written standard work procedures for admissions that include documentation that the client has been oriented to the project and has been familiarized with project policies.
3. The manager of admissions will ensure that documentation that the client has been oriented to the project and has been familiarized with project policies has been obtained from all clients upon admission.
The correction will be maintained by conducting a rigorous review of client records to ensure that the facility has obtained and included in the client record, documentation that the client has been oriented to the project and has been familiarized with project policies.
It is the responsibility of the Facility Director with the Director of Social Services and Finance Director to conduct a review of all client records every 30 days for all clients admitted the previous 30 days, to verify that each client record captures the required documentation, including this documentation that the client has been oriented to the project and has been familiarized with project policies. |
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 seven client records on October 19, 2020 through October 23, 2020. The facility failed to document that clients received an orientation with hours of operation in records, #1, 2, 3, 4, 5, 6 and 7.Client #1 was admitted on August 2, 2019 and was discharged on January 31, 2020. Client #2 was admitted October 29, 2019 and discharged March 19, 2020. Client #3 was admitted October 11, 2019 and discharged May 26, 2020. Client #4 was admitted June 14, 2019 and is still receiving Treatment. .Client #5 was admitted July 6, 2018 and is still receiving Treatment. Client #6 was admitted October 21, 2019 and is still receiving treatment. Client #7 was admitted April 30, 2020 and is still receiving treatment. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency will be corrected by taking the following action steps:
1. The facility director, with the manager of admissions, will review, revise and update the intake and admissions policies and procedures as needed.
2. The facility director, with the manager of admissions will develop and implement written standard work procedures for admissions that include documentation of notification to clients of the facility's hours of operation.
3. The manager of admissions will ensure that documentation of notification to clients of the facility's hours of operation is obtained from all clients upon admission.
The correction will be maintained by conducting a rigorous review of client records to ensure that the facility has obtained and included in the client record, documentation of notification to clients of the facility's hours of operation record.
It is the responsibility of the Facility Director with the Director of Social Services and Finance Director to conduct a review of all client records every 30 days for all clients admitted the previous 30 days, to verify that each client record captures the required documentation, including this documentation of notification to clients of the facility's hours of operation. |
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 seven client records on October 19, 2020 through October 23, 2020. The facility failed to document that clients received an orientation in the records with a fee schedule, #1, 2, 3, 4, 5, 6 and 7.Client #1 was admitted on August 2, 2019 and was discharged on January 31, 2020. Client #2 was admitted October 29, 2019 and discharged March 19, 2020. Client #3 was admitted October 11, 2019 and discharged May 26, 2020. Client #4 was admitted June 14, 2019 and is still receiving Treatment. .Client #5 was admitted July 6, 2018 and is still receiving Treatment. Client #6 was admitted October 21, 2019 and is still receiving treatment. Client #7 was admitted April 30, 2020 and is still receiving treatment. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency will be corrected by taking the following action steps:
1. The facility director, with the manager of admissions, will review, revise and update the intake and admissions policies and procedures as needed.
2. The facility director, with the manager of admissions will develop and implement written standard work procedures for admissions that include documentation of notification to clients of the facility's fee schedule.
3. The manager of admissions will ensure that documentation of notification to clients of the facility's fee schedule is obtained from all clients upon admission.
The correction will be maintained by conducting a rigorous review of client records to ensure that the facility has obtained and included in the client record, documentation of notification to clients of the facility's fee schedule.
It is the responsibility of the Facility Director with the Director of Social Services and Finance Director to conduct a review of all client records every 30 days for all clients admitted the previous 30 days, to verify that each client record captures the required documentation, including this documentation of notification to clients of the facility's fee schedule. |
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 seven client records on October 19, 2020 through October 23, 2020. The facility failed to document that clients received an orientation to familiarize with the services provided in records, #1, 2, 3, 4, 5, 6 and 7.Client #1 was admitted on August 2, 2019 and was discharged on January 31, 2020. Client #2 was admitted October 29, 2019 and discharged March 19, 2020. Client #3 was admitted October 11, 2019 and discharged May 26, 2020. Client #4 was admitted June 14, 2019 and is still receiving Treatment. .Client #5 was admitted July 6, 2018 and is still receiving Treatment. Client #6 was admitted October 21, 2019 and is still receiving treatment. Client #7 was admitted April 30, 2020 and is still receiving treatment. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency will be corrected by taking the following action steps:
1. The facility director, with the manager of admissions, will review, revise and update the intake and admissions policies and procedures as needed.
2. The facility director, with the manager of admissions will develop and implement written standard work procedures for admissions that include documentation of notification to clients of the services that the facility provides.
3. The manager of admissions will ensure that documentation of notification to clients of the services that the facility provides is obtained from all clients upon admission and included in the client's record.
The correction will be maintained by conducting a rigorous review of client records to ensure that the facility has obtained and included in the client record, documentation of notification to clients of the services that the facility provides.
It is the responsibility of the Facility Director with the Director of Social Services and Finance Director to conduct a review of all client records every 30 days for all clients admitted the previous 30 days, to verify that each client record captures the required documentation, including this documentation of notification to clients of the services that the facility provides. |
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 the facility ' s consent to treatment form and seven outpatient client records on October 19, 2020 through October 23, 2020. The facility exceeded what can be release as documented in 4 PA Code 255.5 and 42 CFR Part Two in all client records, #1, 2, 3, 4, and 5 .These were the findings: The form states that elder abuse is a reportable offense.Exceeds 4PA code 255.5 and 42 CFR part 2 regarding information allowed to be released in the HIPPA privacy notice and the Storage and Release of Information section. Does not comply with 4Pa code 255.5 and 42 CFR part 2 in stating a client may revoke consents in writing and does not include other acceptable ways revocation may occur. Client #1 was admitted on August 2, 2019 and was discharged on January 31, 2020. This document was part of the client record.Client #2 was admitted October 29, 2019 and discharged March 19, 2020. This document was part of the client record.Client #3 was admitted October 11, 2019 and discharged May 26, 2020. This document was part of the client record.Client #4 was admitted June 14, 2019 and is still receiving treatment services to the date of this inspection. This document was part of the client record.Client #5 was admitted July 6, 2018 and is still receiving treatment services to the date of this inspection. This document was part of the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency will be corrected by taking the following action steps:
1. The facility director, with the manager of admissions, will review, revise and update the intake and admissions policies and procedures as needed.
2. The facility director, with the manager of admissions will develop and implement written standard work procedures for admissions that include obtaining signed consents to treatment upon admission.
3. The manager of admissions will ensure that a signed consent to treatment has been obtained from all clients upon admission.
The correction will be maintained by conducting a rigorous review of client records to ensure that the client's consent to treatment has obtained and included in the client record.
It is the responsibility of the Facility Director with the Director of Social Services and Finance Director to conduct a review of all client records every 30 days for all clients admitted the previous 30 days, to verify that each client record captures the required documentation, including the consent to treatment. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
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Observations
Based on a review of client records from October 19, 2020 through October 23, 2020. The facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client. Client #1 was admitted on August 2, 2019 and was discharged on January 31, 2020. Documentation in the client's record indicated the comprehensive treatment plan was never completed.Client #2 was admitted October 29, 2019 and discharged March 19, 2020. The comprehensive plan dated 4/24/20 was not signed by the client.Client #3 was admitted October 11, 2019 and discharged May 26, 2020. The comprehensive treatment plan was never completed.Client #4 was admitted June 14, 2019 and is still receiving treatment. The comprehensive treatment plan was never completed.Client #5 was admitted July 6, 2018 and is still receiving treatment. The comprehensive treatment plan dated 8/5/20 was not signed by the client.Client #6 was admitted October 21, 2019 and is still receiving treatment. The comprehensive treatment plan dated 8/10/20, was not signed by the client.Client #7 was admitted April 30, 2020 and is still in treatment. The comprehensive treatment plan dated 8/27/20 was not signed by the client.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The treatment provider shall begin to formulate a preliminary treatment and rehabilitation plan upon intake and assessment. At this time a history is taken and psychosocial evaluation is provided. Documentation of the finalized individual treatment and rehabilitation plan that has been developed in collaboration with the client is to be included in the client record within the required timeframe. The treatment plan shall be signed and dated by the individual rendering services. It shall also be documented that the treatment plan was developed with the client.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, plus 100% of new admissions per month of the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported and reviewed by the Project Director for corrective action. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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 client records from October 19, 2020 through October 23, 2020. The facility failed to ensure that an individual treatment and rehabilitation plan included the type and frequency of services. Client #10 was admitted on June 29, 2020 and still in treatment. The comprehensive treatment plan was dated August 12, 2020. Client #11 was admitted on June 29, 2020 and still in treatment. the comprehensive treatment plan was dated September 9, 2020. Client #12 was admitted on July 21, 2020 and still in treatment. The comprehensive treatment plan was dated September 8, 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The treatment provider shall begin to formulate a preliminary treatment and rehabilitation plan upon intake and assessment. At this time a history is taken and psychosocial evaluation is provided. Documentation of the finalized individual treatment and rehabilitation plan that has been developed in collaboration with the client is to be included in the client record within the required timeframe. The treatment plan shall include written documentation of the type and frequency of rehabilitation services.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, plus 100% of new admissions per month of the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported and reviewed by the Project Director for corrective action. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records from October 19, 2020 through October 23, 2020. The facility failed to ensure that an individual treatment and rehabilitation plan included the proposed type of support service. Client #10 was admitted on June 29, 2020 and still in treatment. The comprehensive treatment plan was dated August 12, 2020. Client #11 was admitted on June 29, 2020 and still in treatment.Comprehensive treatment plan was dated September 9, 2020. Client #12 was admitted on July 21, 2020 and still in treatment. The comprehensive treatment plan was dated September 8, 2020.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The treatment provider shall begin to formulate a preliminary treatment and rehabilitation plan upon intake and assessment. At this time a history is taken and psychosocial evaluation is provided. Documentation of the finalized individual treatment and rehabilitation plan that has been developed in collaboration with the client is to be included in the client record within the required timeframe. The treatment plan shall include written documentation of the proposed types of support services.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, plus 100% of new admissions per month of the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported and reviewed by the Project Director for corrective action. |
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 from October 19, 2020 through October 23, 2020, the facility failed to document the provision of a treatment plan update at least every 30 days for 4 out of 7 client records .Client #1 was admitted on August 2, 2019 and was discharged on January 31, 2020. Client #2 was admitted October 29, 2019 and discharged March 19, 2020. Client #3 was admitted October 11, 2019 and discharged May 26, 2020.Client #4 was admitted June 14, 2019 and is still receiving treatment. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment and rehabilitation plans shall be reviewed and updated at least every sixty days. The treatment plan update shall include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, per month of the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported and reviewed by the Project Director for corrective action.
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709.93(a)(6) 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:
(6) Individual treatment and rehabilitation plan.
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Observations
Based on a review of client records from October 19, 2020 through October 23, 2020, the facility failed to ensure that an individual treatment and rehabilitation plan was developed. Client #1 was admitted on August 2, 2019 and was discharged on January 31, 2020. Client #3 was admitted October 11, 2019 and discharged May 26, 2020.Client #4 was admitted June 14, 2019 and is still receiving treatment. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall maintain complete client records for every individual in treatment, including a treatment and rehabilitation plan developed with the client.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Project Director will review the policy and procedures with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, plus 100% of all discharged client records for the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported to the Project Director for corrective action. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records from October 19, 2020 through October 23, 2020, the facility failed to document a case consultation for client record # 1, 2, and 3. Client #1 was admitted on August 2, 2019 and was discharged on January 31, 2020. Client #2 was admitted October 29, 2019 and discharged March 19, 2020. Client #3 was admitted October 11, 2019 and discharged May 26, 2020. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Each client's progress shall be reviewed at least quarterly, and more frequently if needed, at a case conference attended by a multidisciplinary team.
Documentation of the case consultation shall be noted in the client's record by the counselor rendering treatment services.
Staff who render treatment services are required to adhere to the program's policy and procedures regarding the completion of client records.
The Project Director will review the policy with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the clinical supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records.
Adherence to the requirements regarding client records will be verified and any problems will be reported and addressed by the Project Director for corrective action. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records from October 19, 2020 through October 23, 2020, the facility failed to document an aftercare plan for client record # 1, 2, and 3. Client #1 was admitted on August 2, 2019 and was discharged on January 31, 2020. Client #2 was admitted October 29, 2019 and discharged March 19, 2020.Client #3 was admitted October 11, 2019 and discharged May 26, 2020. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall maintain a complete client record for every individual in treatment, including an aftercare plan, if applicable.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Project Director will review the policy and procedures with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, plus 100% of all discharged client records for the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported to the Project Director for corrective action. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records from October 19, 2020 through October 23, 2020, the facility failed to document a discharge summary for client record # 1, 2, and 3. Client #1 was admitted on August 2, 2019 and was discharged on January 31, 2020. Client #2 was admitted October 29, 2019 and discharged March 19, 2020. Client #3 was admitted October 11, 2019 and discharged May 26, 2020. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Within a week after discharge, the treatment provider shall enter into the client's record a discharge summary describing the reasons for treatment, services offered, response to treatment and client's status or condition upon discharge.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the Clinical Supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records, plus 100% of all discharged client records for the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported to the Project Director for 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 from October 19, 2020 through October 23, 2020, the facility failed to document a follow up for client records, # 1, 2, and 3. Client #1 was admitted on August 2, 2019 and was discharged on January 31, 2020. Client #2 was admitted October 29, 2019 and discharged March 19, 2020. Client #3 was admitted October 11, 2019 and discharged May 26, 2020. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The client record shall contain follow-up information. When a client has been discharged the project shall, with the written consent of the client and within one week from the day the the client has discharged, attempt to contact the client to determine her disposition at one-week post-discharge. Once the attempt has been made and documented, the project shall consider its obligation to the individual fulfilled.
Staff who render treatment services are required to adhere to the program's policy and procedures regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by December 16, 2020.
Client records will be reviewed at regularly scheduled supervision meetings with the clinical supervisor. Records will be reviewed for completeness, adequacy and accuracy.
The Quality Assurance Committee will also conduct a monthly case review of five active client records and 100% of discharged clients for the previous month.
Adherence to the requirements regarding client records will be verified and any problems will be reported by the Project Director for corrective action. |