INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted November 13, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Chances, 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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709.24 (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
The facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in one of fourteen client records.
Patient #14 was admitted into the outpatient level of care on March 5, 2019 and was discharged April 19, 2019. The project's written policy and procedure stated that the comprehensive treatment plan must be completed within 30 days of admittance. The client record did not have a completed comprehensive treatment plan at the time of discharge, which exceeded the written policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will provide training with therapists on the CHANCES policy of updating treatment plans within 30 days of intake. This training will take place by or on 12/20/2019.
The Program Director will monitor therapist adherence to the standard on a monthly basis during Case Conference meeting. Each new case will be checked to verify compliance with the treatment plan completion policy.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2020.
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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
The facility failed to document in writing that the clients were informed that they may not be deprived of their civil rights solely by reason of treatment in three of fourteen records reviewed.
Client # 5 was admitted into the Intake, Evaluation, and Referral activity on January 29, 2019 and discharged January 29, 2019.
Client # 6 was admitted into the Intake, Evaluation, and Referral activity on February 18, 2019 and discharged February 18, 2019.
Client # 7 was admitted into the Intake, Evaluation, and Referral activity on February 26, 2019 and discharged February 26, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Total Quality Management will re-train Program Director and Intake Admissions Coordinator on the required documentation for clients who received assessment services. TQM will provide training by January 15th, 2020.
Program Director and Admissions Coordinator will review all admissions charts for signed acknowledgement that clients have received notification of their rights. These reviews will occur on a monthly basis.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2020. |
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
The facility failed to document in writing that the clients were informed that they may not be discriminated upon in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in three of fourteen records reviewed.
Client # 5 was admitted into the Intake, Evaluation, and Referral activity on January 29, 2019 and discharged January 29, 2019.
Client # 6 was admitted into the Intake, Evaluation, and Referral activity on February 18, 2019 and discharged February 18, 2019.
Client # 7 was admitted into the Intake, Evaluation, and Referral activity on February 26, 2019 and discharged February 26, 2019.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Total Quality Management will re-train Program Director and Intake Admissions Coordinator on the required documentation for clients who received assessment services. TQM will provide training by January 15th, 2020.
Program Director and Admissions Coordinator will review all admissions charts for signed acknowledgement that clients have received notification of their rights. These reviews will occur on a monthly basis.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2020. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The facility failed to document in writing that the clients were informed that they have the right to inspect their own record in three of fourteen records reviewed.
Client # 5 was admitted into the Intake, Evaluation, and Referral activity on January 29, 2019 and discharged January 29, 2019.
Client # 6 was admitted into the Intake, Evaluation, and Referral activity on February 18, 2019 and discharged February 18, 2019.
Client # 7 was admitted into the Intake, Evaluation, and Referral activity on February 26, 2019 and discharged February 26, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Total Quality Management will re-train Program Director and Intake Admissions Coordinator on the required documentation for clients who received assessment services. TQM will provide training by January 15th, 2020.
Program Director and Admissions Coordinator will review all admissions charts for signed acknowledgement that clients have received notification of their rights. These reviews will occur on a monthly basis.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2020.
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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
The facility failed to document in writing that the clients were informed that they have the right to appeal a decision limiting access to their records to the director in three of fourteen records reviewed.
Client # 5 was admitted into the Intake, Evaluation, and Referral activity on January 29, 2019 and discharged January 29, 2019.
Client # 6 was admitted into the Intake, Evaluation, and Referral activity on February 18, 2019 and discharged February 18, 2019.
Client # 7 was admitted into the Intake, Evaluation, and Referral activity on February 26, 2019 and discharged February 26, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Total Quality Management will re-train Program Director and Intake Admissions Coordinator on the required documentation for clients who received assessment services. TQM will provide training by January 15th, 2020.
Program Director and Admissions Coordinator will review all admissions charts for signed acknowledgement that clients have received notification of their rights. These reviews will occur on a monthly basis.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2020.
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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
The facility failed to document in writing that the clients were informed that they have the right to request the correction of inaccurate irrelevant, outdated or incomplete information in their records in three of fourteen records reviewed.
Client # 5 was admitted into the Intake, Evaluation, and Referral activity on January 29, 2019 and discharged January 29, 2019.
Client # 6 was admitted into the Intake, Evaluation, and Referral activity on February 18, 2019 and discharged February 18, 2019.
Client # 7 was admitted into the Intake, Evaluation, and Referral activity on February 26, 2019 and discharged February 26, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Total Quality Management will re-train Program Director and Intake Admissions Coordinator on the required documentation for clients who received assessment services. TQM will provide training by January 15th, 2020.
Program Director and Admissions Coordinator will review all admissions charts for signed acknowledgement that clients have received notification of their rights. These reviews will occur on a monthly basis.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2020.
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709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
The facility failed to document in writing that the clients were informed that they have the right to submit rebuttal data or memoranda to their own records in three of fourteen records reviewed.
Client # 5 was admitted into the Intake, Evaluation, and Referral activity on January 29, 2019 and discharged January 29, 2019.
Client # 6 was admitted into the Intake, Evaluation, and Referral activity on February 18, 2019 and discharged February 18, 2019.
Client # 7 was admitted into the Intake, Evaluation, and Referral activity on February 26, 2019 and discharged February 26, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Total Quality Management will re-train Program Director and Intake Admissions Coordinator on the required documentation for clients who received assessment services. TQM will provide training by January 15th, 2020.
Program Director and Admissions Coordinator will review all admissions charts for signed acknowledgement that clients have received notification of their rights. These reviews will occur on a monthly basis.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2020.
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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
The facility failed to provide treatment plan updates within the regulatory timeframe in 3 of 7 outpatient client records reviewed.
Client #8 was admitted on February 28, 2019 and was active at the time of inspection. A treatment plan update was completed on May 5, 2019 and a treatment plan update was due no later than July 8, 2019. However, the update was not completed until July 18, 2019.
Client #9 was admitted on December 10, 2018 and was active at the time of inspection. A treatment plan update was completed on April 15, 2019 and the next update was due no later than June 15, 2019. However, the update was not completed until July 19, 2019.
Client #11 was admitted on December 26, 2018 and was discharged November 12, 2019. A treatment plan update was completed on May 28, 2019 and the next update was due no later than July 28, 2019. However, the update was not completed until August 6, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Total Quality Management will re-train Program Director and Intake Admissions Coordinator on the required documentation for clients who received assessment services. TQM will provide training by January 15th, 2020.
Program Director and Admissions Coordinator will review all admissions charts for signed acknowledgement that clients have received notification of their rights. These reviews will occur on a monthly basis.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2020.
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709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
The facility failed to document a facility consent to treatment form in six of seven client records.
Client # 1 was admitted into the intake, evaluation and referral level of care on January 4, 2019 and discharged January 4, 2019.
Client # 2 was admitted into the intake, evaluation and referral level of care on November 8, 2018 and discharged November 8, 2018.
Client # 4 was admitted into the intake, evaluation and referral level of care on December 12, 2018 and discharged December 12, 2018.
Client # 5 was admitted into the intake, evaluation and referral level of care on January 29, 2019 and discharged January 29, 2019.
Client # 6 was admitted into the intake, evaluation and referral level of care on February 18, 2019 and discharged February 18, 2019.
Client # 7 was admitted into the intake, evaluation and referral level of care on February 26, 2019 and discharged February 26, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Total Quality Management will re-train Program Director and Intake Admissions Coordinator on the required documentation for clients who received assessment services. TQM will provide training by January 15th, 2020.
Program Director and Admissions Coordinator will review all admissions charts for signed acknowledgement that clients have received notification of their rights. These reviews will occur on a monthly basis.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2020.
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