INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 14, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Little Creek Outpatient Services LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on a physical plant inspection on September 13, 2022, the facility failed to clearly indicate exits by the use of signs as the second exit door through the adjoining suite did not have exterior exit doors labeled.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/3/22, a discussion with the owner of the building (our Landlord) was had. Exit signs were purchased to properly mark second exit. They will be installed by 10/21/22 by the Director of Operations. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records and discussion with the facility director, the facility failed to follow their written procedures for the management of treatment and rehabilitation services, pertaining to case consultations occurring at least once for each client, in six of nine applicable records reviewed.
Client #5 was admitted to the Partial activity on May 17, 2022 and was discharged on June 28, 2022. There was no documentation of a case consultation in the client record.
Client #6 was admitted to the Partial activity on September 6, 2021 and was discharged on October 25, 2021. There was no documentation of a case consultation in the client record.
Client #9 was admitted to the Outpatient activity on February 16, 2022 and was discharged on April 26, 2022. There was no documentation of a case consultation in the client record.
Client #11 was admitted to the Outpatient activity on October 25, 2021 and was discharged on December 2, 2021. There was no documentation of a case consultation in the client record.
Client #13 was admitted to the Partial activity on February 22, 2022 and was discharged on March 23, 2022. There was no documentation of a case consultation in the client record.
Client #14 was admitted to the Outpatient activity on March 23, 2022 and was discharged on June 21, 2022. There was no documentation of a case consultation in the client record.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
In a Clinical Staff Meeting on 10/6/22, the facility's policy around Case Consultations was reviewed. Copies of the facility's policy on this treatment activity as well as DDAP's correlating licensure standard, were given to all clinicians. The rationale was explained. Clinical team members discussed how to be more diligent in meeting this standard and it was determined that Case Consultation notes will be entered following bi-weekly clinical meetings if a case is discussed, when there is a crisis intervention for a client, or while planning aftercare which requires discussion about the client by the team. Clinical Director will review all charts to assure there is a case consultation in there prior to the client discharging. |
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 fourteen records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client #10 was admitted to the Outpatient activity on February 9, 2022 and was discharged on July 19, 2022. The record contained documentation that personally identifying information was released to another treatment provider on July 19, 2022, however, the client signed consent to release information form to the provider expired on May 10, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was identified by the Clinical Director that there was a stock Release of Information form template in our EMR system, that was automatically set to expire at 6 months rather than the standard 1 year which was written in the release itself that the client signed. This was a glitch with the EMR as the form itself was accurate, but the system automatically expired the form after 6 months. On 9/14/22, the Clinical Director went into the form template and adjusted the trigger for expiring the form, to 365 days, as is documented in the form.
This form has been permanently corrected in our EMR by the Clinical Director, and there is no access/chance that the old form with 6-month expiration date can ever be accessed by anyone. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of fourteen client records, the facility failed to include documentation of all the required client rights, including that the project may not discriminate in the provision of services on the basis of ethnicity, marital status, sexual orientation, handicap or religion, in eleven records reviewed.
Client #2 was admitted to the Partial activity on February 16, 2022 and discharged on March 24, 2022.
Client #3 was admitted to the Partial activity on August 22, 2022 and was active at the time of the inspection.
Client #4 was admitted to the Partial activity on August 31, 2022 and was active at the time of the inspection.
Client #5 was admitted to the Partial activity on May 17, 2022 and was discharged on June 28, 2022.
Client #7 was admitted to the Outpatient activity on July 5, 2022 and was active at the time of the inspection.
Client #8 was admitted to the Outpatient activity on April 4, 2022 and was active at the time of the inspection.
Client #9 was admitted to the Outpatient activity on February 16, 2022 and was discharged on April 26, 2022.
Client #10 was admitted to the Outpatient activity on February 9, 2022 and was discharged on July 19, 2022.
Client #12 was admitted to the Outpatient activity on March 24, 2022 and was discharged on April 13, 2022.
Client #13 was admitted to the Partial activity on February 22, 2022 and was discharged on March 23, 2022.
Client #14 was admitted to the Outpatient activity on March 23, 2022 and was discharged on June 21, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/14/2022, Clinical Director edited the Client Rights and Responsibilities template form to include protection against discrimination on the basis of ethnicity, marital status, sexual orientation, handicap or religion, in addition to other attributes already identified. This has now permanently been corrected for all incoming clients. All active clients were informed of this right change in their counseling sessions during the week of 10/16-10/21, and if they were not yet seen for session that week, will be informed in their next sessions, no later than 10/31/21, by their respective Primary Counselors. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of fourteen client records, the facility failed to include documentation of all the required client rights, including that clients have the right to appeal a decision limiting access to their records to the director, in eleven records reviewed.
Client #2 was admitted to the Partial activity on February 16, 2022 and discharged on March 24, 2022.
Client #3 was admitted to the Partial activity on August 22, 2022 and was active at the time of the inspection.
Client #4 was admitted to the Partial activity on August 31, 2022 and was active at the time of the inspection.
Client #5 was admitted to the Partial activity on May 17, 2022 and was discharged on June 28, 2022.
Client #7 was admitted to the Outpatient activity on July 5, 2022 and was active at the time of the inspection.
Client #8 was admitted to the Outpatient activity on April 4, 2022 and was active at the time of the inspection.
Client #9 was admitted to the Outpatient activity on February 16, 2022 and was discharged on April 26, 2022.
Client #10 was admitted to the Outpatient activity on February 9, 2022 and was discharged on July 19, 2022.
Client #12 was admitted to the Outpatient activity on March 24, 2022 and was discharged on April 13, 2022.
Client #13 was admitted to the Partial activity on February 22, 2022 and was discharged on March 23, 2022.
Client #14 was admitted to the Outpatient activity on March 23, 2022 and was discharged on June 21, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/14/2022, Clinical Director edited the Client Rights and Responsibilities template form to include the right for all clients to appeal a decision limiting access to their records, to the Director. This has now permanently been corrected for all incoming clients. All active clients were informed of this right change in their counseling sessions during the week of 10/16-10/21, and if they were not yet seen for session that week, will be informed in their next sessions, no later than 10/31/21, by their respective Primary Counselors.
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of fourteen client records, the facility failed to include documentation of all the required client rights, including that clients have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records, in eleven records reviewed.
Client #2 was admitted to the Partial activity on February 16, 2022 and discharged on March 24, 2022.
Client #3 was admitted to the Partial activity on August 22, 2022 and was active at the time of the inspection.
Client #4 was admitted to the Partial activity on August 31, 2022 and was active at the time of the inspection.
Client #5 was admitted to the Partial activity on May 17, 2022 and was discharged on June 28, 2022.
Client #7 was admitted to the Outpatient activity on July 5, 2022 and was active at the time of the inspection.
Client #8 was admitted to the Outpatient activity on April 4, 2022 and was active at the time of the inspection.
Client #9 was admitted to the Outpatient activity on February 16, 2022 and was discharged on April 26, 2022.
Client #10 was admitted to the Outpatient activity on February 9, 2022 and was discharged on July 19, 2022.
Client #12 was admitted to the Outpatient activity on March 24, 2022 and was discharged on April 13, 2022.
Client #13 was admitted to the Partial activity on February 22, 2022 and was discharged on March 23, 2022.
Client #14 was admitted to the Outpatient activity on March 23, 2022 and was discharged on June 21, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/14/2022, Clinical Director edited the Client Rights and Responsibilities template form to include the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records. This has now permanently been corrected for all incoming clients. All active clients were informed of this right change in their counseling sessions during the week of 10/16-10/21, and if they were not yet seen for session that week, will be informed in their next sessions, no later than 10/31/21, by their respective Primary Counselors.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of fourteen client records, the facility failed to document that the client was notified in writing of a decision to involuntarily terminate the client ' s treatment at the project in one of one applicable record reviewed.
Client #1 was admitted to the Partial activity on March 20, 2022 and was administratively discharged on April 4, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In a Clinical Team Staff Meeting on 10/6/22, the Clinical Director reviewed the facility's policy and procedure around documenting in a client's record that they are being involuntarily terminated. Clinicians were reminded that a Client must acknowledge, in writing, that they were informed of this decision. This written documentation must be made part of their permanent record. A form was created in the EMR that is to be utilized in the event that a Client is being Therapeutically Discharged. Clients are to sign this. In the event a client refuses to sign this document verifying they have been informed of involuntary discharge, the Counselor must document in the client record, an attempt was made and the client refused. All Therapeutic Discharges (involuntary discharges) will be reviewed in bi-weekly Clinical Staff Meetings by the Clinical Director with the Clinical Team, for the next 6 months, to ensure this protocol is being followed. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of seven records, the facility failed to ensure that counseling was provided to clients on a regular and scheduled basis, that included individual counseling, at least twice weekly in three of seven applicable records reviewed.
Client #3 was admitted to the Partial activity on August 22, 2022 and was active at the time of the inspection. The record contained documentation of only one individual counseling session per week offered between August 25, 2022 and the date of the inspection.
Client #5 was admitted to the Partial activity on May 17, 2022 and was discharged on June 28, 2022. The record contained documentation of only one individual counseling session per week offered between May 23, 2022 and June 9, 2022.
Client #6 was admitted to the Partial activity on September 9, 2021 and was discharged on October 25, 2021. The record contained documentation of only one individual counseling session per week offered the weeks of September 23, 2021 and September 27, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In a Clinical Team Staff Meeting on 10/6/22, Clinical Director discussed with the entire treatment team the DDAP requirement that PHP (2.5 LOC) clients be met with twice per week for individual counseling sessions. All current PHP clients' individual counseling schedules were adjusted to include 2 individual counseling sessions per week.
For the next 2 months, the Clinical Director and Clinical Supervisor will review all PHP client schedules to ensure they are being scheduled and seen 2x weekly. In bi-weekly Clinical Staff Meetings, scheduling of PHP clients will be reviewed will all Counselors, until 12/31/22. |
709.84(e) LICENSURE Project management services
709.84. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy in two of four applicable records reviewed.
Client #1 was admitted on March 20, 2022 and was discharged on April 4, 2022. The record did not contain documentation of follow up information with the patient within 30 days of discharge in accordance with the facility policy.
Client #6 was admitted on September 9, 2021 and was discharged on October 25, 2021. The record did not contain documentation of follow up information with the client within 30 days of discharge in accordance with the facility policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In a Clinical Team meeting on 10/6/2022, the Clinical Director advised all Clinicians to contact our Alumni Coordinator to inform him when someone has been discharged. That way, he can add them to his follow-up call schedule and do follow-ups as designed and laid out in our P&P. Clinical Director will meet with Alumni Coordinator and Clinical Team bi-weekly, to ensure this is happening, through the end of December 2022. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy in three of five applicable records reviewed.
Client #9 was admitted on February 16, 2022 and was discharged on April 26, 2022. The record did not contain documentation of follow up information with the patient within 30 days of discharge in accordance with the facility policy.
Client #10 was admitted on February 9, 2022 and was discharged on July 19, 2022. The record did not contain documentation of follow up information with the client within 30 days of discharge in accordance with the facility policy.
Client #11 was admitted on October 25, 2021 and was discharged on December 2, 2021. The record did not contain documentation of follow up information with the client within 30 days of discharge in accordance with the facility policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In a Clinical Team meeting on 10/6/2022, the Clinical Director advised all Clinicians to contact our Alumni Coordinator to inform him when someone has been discharged. That way, he can add them to his follow-up call schedule and do follow-ups as designed and laid out in our P&P. Clinical Director will meet with Alumni Coordinator and Clinical Team bi-weekly, to ensure this is happening, through the end of December 2022.
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