INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Services of Beaver Valley 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 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
There was no documentation that fire drills had been completed for the months of June, July, and August of 2021.
These findings were reviewed with facilty staff during the licensing process.
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Plan of Correction
The Director will conduct unannounced random fire drills on a monthly basis. The Director will record the results of the fire drills promptly on the fire drill logs and store them in the Fire Drill folder for review. Full compliance will be achieved 12/20/21. The Board of Directors will oversee the performance of the Director. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on the review of administrative documents, the facility failed to obtain an annual audit for the fiscal year of July 1, 2019 to June 30, 2020.
There was no documentation provided of the annual audit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will secure the services of an independent CPA to complete the annual audit. The Board of Directors will oversee this process. |
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 the review of client records, the facility failed to obtain an informed and voluntary consent from the client in two of four records.
Client # 1 was admitted on April 27, 2021 and discharged on June 21, 2021. Consents to release information for the funder and government agencies were not signed by the client. Information was sent to the funder and the government agencies.
Client # 2 was admitted on April 8, 2021 and discharged on June 24, 2021. Consents to release information for the funder and government agencies were not signed by the client. Information was sent to the funder and the government agencies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #1 and #2 were seen at the previous address of Drug and Alcohol Services (DASBV) and had been discharged from DASBV at that location. They are no longer in the service delivery system. All future clients will sign informed and voluntary consents at the time of each individual's intake evaluation. The Director, a PA State Licensed Psychologist, will oversee the charts and no information will be provided unless the appropriate signature is obtained for release of information to the appropriate referral source. Full compliance will be obtained as soon as the agency receives the necessary medical insurance authorization (Promise number)and can begin admitting clients. The Board of Directors will oversee the director's performance. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent that included the dated signature of the client in two of four records.
Client # 1 was admitted on April 27, 2021 and discharged on June 21, 2021. Consents to release information for the funder and government agencies were not signed by the client.
Client # 2 was admitted on April 8, 2021 and discharged on June 24, 2021. Consents to release information for the funder and government agencies were not signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #1 and #2 were seen at the previous location of Drug and Alcohol Services (DASBV). Their cases have been closed and they are no longer accessible to DASBV at its new location. All future clients will sign informed and voluntary consents at each intake evaluation session. The Director, a PA State Licensed Psychologist, will oversee the completion of these forms and ensure that all appropriate signatures are obtained on the consent to release information forms. Full compliance will be achieved as soon as the facility begins admitting clients to outpatient services. The Board of Directors will oversee the Director's work. |
709.30 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.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement by the client that they were notified of their rights in four of four records.
There was no documentation that the clients were notified of the required rights in client records # 1, 2, 3 and 4.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Clients Rights and Responsibilities form will be provided at each intake evaluation session. The form will be presented so that the client can read his/her rights and responsibilities and the Director will review these conditions with each client to ensure client comprehension and acceptance. The client will be required to initial and sign the form indicating receipt and comprehension of the conditions (No client may be deprived of a civil right solely by reason of treatment, the project may not discriminate on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, a client has a right to inspect his/her own records, the client has a right to appeal a decision, the client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records, and the client has the right to submit rebuttal data or memoranda to his/her own records).Full compliance will be achieved whenever clients are admitted to the facility to begin outpatient services. The Board of Directors will oversee the Director's performance. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on the review of administrative documentation, the facility failed to document a data collection and recordkeeping system.
There was no record keeping system provided that that allowed for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director shall collect demographic information on each client with the BDAP Screening Tool at the time the client calls to schedule the first appointment. Clients will be given a Client Satisfaction Questionnaire by the Director at least three times during the course of treatment. This instrument will be used to collect feedback regarding the treatment experience at Intake, midway during the treatment process, and at the time of discharge for quality control analysis and purposes. The Director will also contract with a software company for research in order to predict treatment outcomes based on demographics, socioeconomic status, and co-occurring psychiatric disorders. The Board of Directors will be responsible for the oversight of the Director's work. Full compliance will be achieved as clients are admitted to the program and case histories are developed and recorded. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on the review of administrative records, the facility failed to provide a recordkeeping system that allow for the identification of clients ' admissions and discharges within a specific time.
There were no open clients at the time of the inspection. The facility was not able to provide a list of closed charts or a record keeping system. The closed records had been placed in storage and listed in alphabetical order. The closed charts included all the years of closed charts. It was not possible to identify client's admission and discharges within a specific time.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director shall devise a plan to digitally record all clients' names, and admission and discharge dates so that retrieval of this information can be easily facilitated within specific time frames as needed. Full compliance will begin once clients are admitted to outpatient services. The Board of Directors will be responsible for the oversight of the Director's performance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in four of four records.
Four client records were reviewed. Client records # 1, 2, 3 and 4 were missing documentation of a psychosocial evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #1,#2,#3,and #4 were treated at the former location of Drug and Alcohol Services and their cases have been closed. The psychosocial evaluations for these individuals cannot be completed since clients 1, 2, 3, and 4 are no longer in the current service delivery system. Part of the admission process for each client is to undergo a psychosocial evaluation so that the appropriate treatment goals can be identified. The Director, a PA State Licensed Psychologist, will complete the psychosocial evaluation within the first two sessions of the admission process for each client requesting admission to the facility. Full compliance will be achieved once clients are admitted to outpatient services. The Board of Directors will oversee the Director's work. |
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 the review of client records, the facility failed to review and update treatment plans at least every sixty days in two of two records.
Client # 3 was admitted on January 20, 2021 and discharged on May 26, 2021. A treatment plan update was due to be completed by April 17, 2021. There was no update documented.
Client # 4 was admitted on February 11, 2021 and discharged on June 9, 2021. A treatment plan update was due to be completed by May 16, 2021. There was no update documented.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the annual inspection conducted on December 17-18, 2019.
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Plan of Correction
Clients #3 and #4 were treated at the former location of Drug and Alcohol Services and their cases have been closed. Lack of contact will not permit the treatment plan updates to be completed. The Director will devise and contract with a digital control system that will ensure that treatment plan updates are completed in every 60 days. He will complete the treatment plan updates when needed. Full compliance will be achieved once clients are accepted for treatment . The Board of Directors will oversee the Director's performance. |
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 the review of client records, the facility failed to document a discharge summary in four of four records.
Client records # 1, 2, 3 and 4 were discharged clients. There were no discharge summaries documented.
Client # 1 was discharged on June 21, 2021
Client # 2 was discharged on June 24, 2021
Client # 3 was discharged on May 26, 2021
Client # 4 was discharged on June 9, 2021
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #1,#2,#3,and #4 were discharged from the facility of Drug and Alcohol Services at its previous location. No discharge summaries were found in their charts and cannot be replaced due to lack of contact with these clients. The Director, a PA State Licensed Psychologist, will complete the discharge summary within 5 days of the actual discharge date and include the necessary information(identification of treatment issues and goals, client's response to treatment, a summary of client's progress, aftercare plan, and prognosis) to record a history of the client's participation at the facility. Full compliance will be achieved as the clients are admitted to and discharged from treatment. The Board of Directors will oversee the Director's work. |
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 the review of client records, the facility failed to document a follow-up in four of four records.
Per policy, follow-up is to be completed within 30 days of discharge.
Client records # 1, 2, 3 and 4 did not document follow-up information.
Client # 1 was discharged on June 21, 2021
Client # 2 was discharged on June 24, 2021
Client # 3 was discharged on May 26, 2021
Client # 4 was discharged on June 9, 2021
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up forms were missing in the charts of Clients #1,#2,#3, and #4. Again, these were clients that were treated at the previous location of Drug and Alcohol Services. The Director will devise a digital notification system to alert him when the follow up contact is due up to 6 months after the discharge date. The Director will complete Follow up forms in a timely fashion and documentation will be included in the chart. Full compliance will begin once clients are admitted to treatment and follow ups will be done in the appropriate time frame once the treatment process is completed. The Board of Directors will oversee the Director's work. |