INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 30, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ascend Clincial Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in two of fourteen client records. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #10 was admitted on December 5, 2023 and was still active at the time of the inspection.
Client #14 was admitted on April 21, 2023 and was discharged on August 18, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/29/2024, a training will be conducted for all clinical staff regarding the need to obtain consents for the release of information including for client funding sources prior to releasing client information. As part of the training, the Facility Director will ensure there is a documented review of the organization's Confidentiality Policy.
To ensure ongoing compliance with 709.28, the Lead Counselor/Compliance Officer will conduct monthly chart reviews to monitor compliance with internal policies and regulatory standards associated with the completion of consents for the release of information.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered in two of five applicable client records
Client #3 was admitted on January 3, 2024 and was still active at the time of the inspection. Client was prescribed Insulin Glargine Solostar to be given two times daily. There was no documentation of the medication being administered or the reason not administered for the following dates:
January 13, 2024
January 14, 2024
January 17, 2024
January 20, 2024
Client #4 was admitted on January 16, 2024 and was still active at the time of the inspection, Client was prescribed Amitriptyline HCI 10 mg to be given two times daily. There was no documentation of the medication being administered or the reason not administered for the following dates:
January 18, 2024 at 20:00
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A training will be provided by 02/29/2024 to all staff responsible for supervising the process of medication self-administration. This training will focus on completion of the medication administration record (MAR) when medication is self-administered or when self-administration is refused.
To ensure ongoing compliance with 709.32, the Compliance Officer will conduct monthly chart reviews to monitor compliance with internal policies and regulatory standards for medication control.
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709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of residential client records, the facility failed to provide a complete client record, which is to include a discharge summary in one out of three applicable records reviewed.
Client #7 was admitted on July 31, 2023 and was discharged on August 9, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 02/29/2023, a discharge summary for client 7 will be entered into the client record.
A training will be provided by 02/29/2024 related to the need to maintain a complete client record that include discharge summaries.
To ensure ongoing compliance with 709.53, the clinical supervisor/lead counselor, in collaboration with the Compliance Officer, will conduct monthly chart reviews to monitor for compliance with internal policies and regulatory standards related to completion of discharge summaries.
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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 residential client records, the facility failed to provide a complete client record, which is to include follow up information in one out of three applicable records reviewed.
Client #7 was admitted on July 31, 2023 and was discharged on August 9, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 02/29/2023, a documented follow-up call will be completed for client 7.
A training will be provided by 02/29/2024 related to the need to maintain a complete client record that include follow-up information.
To ensure ongoing compliance with 709.53(a)(11), the clinical supervisor/lead counselor, in collaboration with the Compliance Officer, will conduct monthly chart reviews to monitor for compliance with internal policies and regulatory standards related to documentation of follow-up information.
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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 outpatient client records, the facility failed to provide a complete client record, which is to include a discharge summary in one out of three applicable records reviewed.
Client #12 was admitted on May 10, 2023 and was discharged on September 30, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 02/29/2023, a discharge summary for client 12 will be entered into the client record.
A training will be provided by 02/29/2024 related to the need to maintain a complete client record that include discharge summaries.
To ensure ongoing compliance with 709.53, the clinical supervisor/lead counselor, in collaboration with the Compliance Officer, will conduct monthly chart reviews to monitor for compliance with internal policies and regulatory standards related to completion of discharge summaries.
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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 outpatient client records, the facility failed to provide a complete client record, which is to include follow up information in three out of three applicable records reviewed.
Client #12 was admitted on May 10, 2023 and was discharged on September 30, 2023.
Client #13 was admitted August 3, 2023 and was discharged on December 5, 2023.
Client #14 was admitted on April 21, 2023 and was discharged on August 18, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 02/29/2023, a documented follow-up call will be completed for client 12.
A training will be provided by 02/29/2024 related to the need to maintain a complete client record that include follow-up information.
To ensure ongoing compliance with 709.53(a)(11), the clinical supervisor/lead counselor, in collaboration with the Compliance Officer, will conduct monthly chart reviews to monitor for compliance with internal policies and regulatory standards related to documentation of follow-up information.
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