INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 25, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Public Health Management Corporation d/b/a PHMC Pathways to Recovery 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure a written individual training plan was developed annually for each employee, with input from both the employee and the supervisor, in one of six personnel records reviewed. Employee #5 was hired as a counselor on November 7, 2022. There was no documentation of an individual training plan for the current training year as of the date of inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
All active staff at PTR without a completed Individual Training Plan on file at PTR will complete a new Individualized Training Plan with input from both the employee and supervisor by 8/30/2024.
Staff will During staff orientation, within 30 days of hire, all new staff will complete the initial PTR Individual Staff Training Plan with their assigned supervisor. Every year, during the month of January, all existing staff will complete the PTR Individual Staff Training Plan annual update Plan with their assigned supervisor. Both staff and supervisor, prior to signing and dating the initial or annual update Staff Training Plans, will individualize the Staff Training Plan by adding information (e.g. goals, comments) specific to that staff member. A copy will be offered to the staff member, and the original will be reviewed by the Program Director for completeness prior to being placed in the staff's personnel file.
All staff and supervisors will be trained on this plan of corrective by 8/30/2024. |
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of three applicable personnel records reviewed.Employee #6 was hired as a counselor on February 23, 2023 and was due to receive the HIV/AIDS training and the TB/STD training no later than February 23, 2024. There was no documentation of the completion of either training at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
All active staff at PTR without completed Mandatory Communicable Disease Trainings on file at PTR within required timeframes as described by 704.11(c)(1) will complete those training courses by 9/30/2024.
During staff orientation, within 30 days of hire, all new staff will complete the initial PTR Individual Staff Training Plan with their assigned supervisor. Every year, during the month of January, all existing staff will complete the PTR Individual Staff Training Plan annual update Plan with their assigned supervisor. Supervisors will review the PA Code 704.11 DDAP Training requirements and timeframes with the staff members during their Training Plan development meeting. Supervisors will instruct staff members on how to sign up and complete the training courses, including 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics, and will develop a plan to complete those DDAP training courses. During regular supervision/staff meetings (e.g. monthly), supervisors will review staff compliance with meeting the DDAP training course completion requirements. Supervisors will review their assigned staff member's course completions with the program director during their regular supervisor staff meetings (e.g. monthly). Compliance with staff training course completion requirements will be documented on staff supervision notes.
All staff and supervisors will be trained on this plan of corrective by 8/30/2024.
|
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of personnel records, the facility failed to ensure the project director and the facility director completed at least 12 clock hours of annual training during the facility's January 2023 through December 2023 training year in one of one applicable personnel record reviewed.Employee #1 was hired as the project director/facility director on March 2, 2021. The personnel record documented 6.5 hours of annual training during the reviewed period.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility/Project Director will be instructed by their Supervisor to review 704.11 training hour requirements by 8/30/2024 and will sign agreement to a plan to complete the required training hours for the current training year (calendar year 2024).
During staff orientation, within 30 days of hire, all new staff will complete the initial PTR Individual Staff Training Plan with their assigned supervisor. Every year, during the month of January, all existing staff , including the Facility/Project director, will complete the PTR Individual Staff Training Plan annual update Plan with their assigned supervisor. Supervisors will review the PA Code 704.11 DDAP Training requirements and timeframes with the staff members during their Training Plan development meeting. Supervisors will instruct staff members on how to sign up and complete the training courses, including the Facility/Project director completing at least 12 clock hours of annual training, and will develop a plan to complete the DDAP required training hours. During regular supervision/staff meetings (e.g. monthly), supervisors will review staff compliance with meeting the DDAP training course completion requirements. Supervisors will review their assigned staff member's course completions with the program director during their regular supervisor staff meetings (e.g. monthly). Compliance with staff training course completion requirements will be documented on staff supervision notes.
All staff and supervisors will be trained on this plan of corrective by 8/30/2024.
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to ensure counselors completed at least 25 clock hours of annual training during the facility's January 2023 through December 2023 training year in one of one applicable personnel record reviewed. Employee #5 was hired as a counselor on November 7, 2022. The personnel record documented 19 hours of annual training during the reviewed period. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
All active Counselors will be instructed by their Supervisor(s) to review 704.11 training hour requirements by 8/30/2024 and will sign agreement to a plan to complete the required training hours for the current training year (calendar year 2024).
During staff orientation, within 30 days of hire, all new staff will complete the initial PTR Individual Staff Training Plan with their assigned supervisor. Every year, during the month of January, all existing staff , including the counselors , will complete the PTR Individual Staff Training Plan annual update Plan with their assigned supervisor. Supervisors will review the PA Code 704.11 DDAP Training requirements and timeframes with the staff members during their Training Plan development meeting. Supervisors will instruct staff members on how to sign up and complete the training courses, including the project director and the facility director completing at least 25 clock hours of annual training, and will develop a plan to complete the DDAP required training hours. During regular supervision/staff meetings (e.g. monthly), supervisors will review staff compliance with meeting the DDAP training course completion requirements. Supervisors will review their assigned staff member's course completions with the program director during their regular supervisor staff meetings (e.g. monthly). Compliance with staff training course completion requirements will be documented on staff supervision notes.
All staff and supervisors will be trained on this plan of corrective by 8/30/2024.
|
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in four of eight client records reviewed.Client #1 was admitted to the partial hospitalization activity on April 23, 2024 and was active at the time of the inspection. There were two blank release of information forms that were signed and dated by the client on April 23, 2024; however, the name of the person, agency, or organization to whom the disclosures were to be made to was not documented on both release forms. Client #2 was admitted to the partial hospitalization activity on April 30, 2024 and was active at the time of the inspection. A blank release of information form was signed and dated by the client on April 30, 2024; however, the name of the person, agency, or organization to whom the disclosure was to be made to was not documented on the release form. Client #7 was admitted to the partial hospitalization activity on August 8, 2023 and was discharged on November 16, 2023. There were three blank release of information forms that were signed and dated by the client on August 8, 2023; however, the name of the person, agency, or organization to whom the disclosures were to be made to was not documented on any of the release forms. Additionally, there was a release of information form to an insurance carrier, signed and dated by the client on August 8, 2023; however, the specific name of the person, agency, or organization to whom the disclosure was to be made to was not documented on the release form.Client #8 was admitted to the partial hospitalization activity on September 15, 2023 and was discharged on November 28, 2023. There were three blank release of information forms that were signed and dated by the client on September 18, 2023; however, the name of the person, agency, or organization to whom the disclosures were to be made to was not documented on any of the release forms. Additionally, there was a release of information form to an insurance carrier, signed and dated by the client on September 18, 2023; however, the client's social security number was documented in the section where the name of the person, agency, or organization to whom the disclosure was to be made to should have been. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director will conduct an internal review of all active client file documentation of Consent for the Release of Information (ROI), including that documentation includes 709.28 (c) (1) required information: in writing and include, but not be limited to: (1) Name of the person, agency or organization to whom disclosure is made. Errors and incomplete documentation of Consent for ROI discovered during the internal review will be amended, signed, and dated, with consent from the client, by 8/30/2024.
Prior to disclosure of information, all staff will be responsible to obtain an informed and voluntary consent for Release of Information (ROI) from the client, documented in the official client record per PA Code 709.28 (c) Confidentiality requirements.
During the intake admission process, Consent for Release of Information will be discussed and completed for Insurers, Primary Care Physicians (PCP), Dentists, Medical Specialists , treatment providers, and any other involved disclosure parties. Prior to disclosure of information, staff will ensure that there is a complete and valid/ signed ROI on file in the client record for the 3rd party. If not, then the staff member will discuss the disclosure with the client, and obtain written documented consent prior to making the disclosure. Documentation of the consent and the disclosure will be placed in the official client record.
As part of the Individualized Staff Training Plan development, within 30 days of hire, supervisors will instruct every staff member assigned to them to complete a DDAP Approved Confidentiality Training Course within 365 days of hire, which includes information about obtaining Consent for Release of Information.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that complete and valid ROI documentation is present in the official client record, and that ROIs are in use during communications with outside parties. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2024.
|
709.28 (c) (2) 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:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to document the specific information to be released on consent to release information forms in four of eight client records reviewed. Client #1 was admitted to the partial hospitalization activity on April 23, 2024 and was active at the time of the inspection. There were two blank release of information forms that were signed and dated by the client on April 23, 2024; however, the specific information to be disclosed was not documented on both release forms. Client #2 was admitted to the partial hospitalization activity on April 30, 2024 and was active at the time of the inspection. A blank release of information form was signed and dated by the client on April 30, 2024; however, the specific information to be disclosed was not documented on the release form. Client #7 was admitted to the partial hospitalization activity on August 8, 2023 and was discharged on November 16, 2023. There were three blank release of information forms that were signed and dated by the client on August 8, 2023; however, the specific information to be disclosed was not documented on any of the release forms. Client #8 was admitted to the partial hospitalization activity on September 15, 2023 and was discharged on November 28, 2023. There were three blank release of information forms that were signed and dated by the client on September 18, 2023; however, the specific information to be disclosed was not documented on any of the release forms. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director will conduct an internal review of all active client file documentation of Consent for the Release of Information (ROI), including that documentation includes 709.28 (c) (2) required information: in writing and include, but not be limited to: (2) Specific information disclosed. Errors and incomplete documentation of Consent for ROI discovered during the internal review will be amended, signed, and dated, with consent from the client, by 8/30/2024.
Prior to disclosure of information, all staff will be responsible to obtain an informed and voluntary consent for Release of Information (ROI) from the client, documented in the official client record per PA Code 709.28 (c) Confidentiality requirements.
During the intake admission process, Consent for Release of Information will be discussed and completed for Insurers, Primary Care Physicians (PCP), Dentists, Medical Specialists , treatment providers, and any other involved disclosure parties. Prior to disclosure of information, staff will ensure that there is a complete and valid/ signed ROI on file in the client record for the 3rd party. If not, then the staff member will discuss the disclosure with the client, and obtain written documented consent prior to making the disclosure. Documentation of the consent and the disclosure will be placed in the official client record.
As part of the Individualized Staff Training Plan development, within 30 days of hire, supervisors will instruct every staff member assigned to them to complete a DDAP Approved Confidentiality Training Course within 365 days of hire, which includes information about obtaining Consent for Release of Information.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that complete and valid ROI documentation is present in the official client record, and that ROIs are in use during communications with outside parties. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2024.
|
709.28 (c) (3) 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:
(3) Purpose of disclosure.
|
Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on release of information forms in four of eight client records reviewed. Client #1 was admitted to the partial hospitalization activity on April 23, 2024 and was active at the time of the inspection. There were two blank release of information forms that were signed and dated by the client on April 23, 2024; however, the purpose of the disclosure was not documented on both release forms. Client #2 was admitted to the partial hospitalization activity on April 30, 2024 and was active at the time of the inspection. A blank release of information form was signed and dated by the client on April 30, 2024; however, the purpose of the disclosure was not documented on the release form. Client #7 was admitted to the partial hospitalization activity on August 8, 2023 and was discharged on November 16, 2023. There were three blank release of information forms that were signed and dated by the client on August 8, 2023; however, the purpose of the disclosure was not documented on any of the release forms. Client #8 was admitted to the partial hospitalization activity on September 15, 2023 and was discharged on November 28, 2023. There were three blank release of information forms that were signed and dated by the client on September 18, 2023; however, the purpose of the disclosure was not documented on any of the release forms. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director will conduct an internal review of all active client file documentation of Consent for the Release of Information (ROI), including that documentation includes 709.28 (c) (2) required information: in writing and include, but not be limited to: (3) Purpose of the disclosure. Errors and incomplete documentation of Consent for ROI discovered during the internal review will be amended, signed, and dated, with consent from the client, by 8/30/2024.
Prior to disclosure of information, all staff will be responsible to obtain an informed and voluntary consent for Release of Information (ROI) from the client, documented in the official client record per PA Code 709.28 (c) Confidentiality requirements.
During the intake admission process, Consent for Release of Information will be discussed and completed for Insurers, Primary Care Physicians (PCP), Dentists, Medical Specialists , treatment providers, and any other involved disclosure parties. Prior to disclosure of information, staff will ensure that there is a complete and valid/ signed ROI on file in the client record for the 3rd party. If not, then the staff member will discuss the disclosure with the client, and obtain written documented consent prior to making the disclosure. Documentation of the consent and the disclosure will be placed in the official client record.
As part of the Individualized Staff Training Plan development, within 30 days of hire, supervisors will instruct every staff member assigned to them to complete a DDAP Approved Confidentiality Training Course within 365 days of hire, which includes information about obtaining Consent for Release of Information.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that complete and valid ROI documentation is present in the official client record, and that ROIs are in use during communications with outside parties. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2024.
|
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.
|
Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion in eight of eight client records reviewed.In each client record reviewed, the non-discrimination rights acknowledgement form, signed by all of the clients, was missing creed and ethnicity.This is a repeat citation from the June 27, 2023 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective immediately , as of 7/23/2024, The Client rights document is amended to prompt for written acknowledgement by clients that they have been notified of their rights that 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.
Effective immediately , as of 7/23/2024, all existing and new clients will be prompted by admissions and counselor staff for written acknowledgement that they have been notified of those rights, and the documentation placed in their file, by 8/30/2024.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that complete and valid Client Rights documentation is present in the official client record. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2024.
|
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.
|
Observations
Based on an administrative review, the facility failed to maintain a data collection and record keeping system that allowed for the efficient retrieval of data needed to measure the project's performance.The facility was unable to produce client paper-records in an efficient manner after they were requested. The records were provided to the DDAP representative after more than an hour of being requested. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director will conduct an internal review of Data collection and record keeping system by 8/30/2024. The review will discover if the filing and retrieval mechanisms are adequate for immediate retrieval of client paper files by the stakeholder parties, including licensors from the Department. The review will check that client paper files are filed in orderly manner as described by § 709.31(a) for timely retrieval. Any inappropriately filed client record information will be refiled by 8/30/2024. Effective immediately, as of 7/23/2024, all client documents in the Data collection and record keeping system (filing room cabinets) must not be removed from the filing room without permission from the program or clinical director. Any client records removed from the filing system (cabinets) must be returned to the filing system (cabinets) in filing order (alphabetical by last name) before the end of each business day. The Clinical Director will conduct a visual inspection of the facility and filing systems at the end of each business day to observe that files are in the filing system in order, so that they are immediately retrievable.
All staff and supervisors will be trained by the Project Director by 8/30/2024 on 709.31. Data collection system, and informed that data collection and recordkeeping systems are in place to allow for the efficient retrieval of data needed to measure the project' s performance in relationship to its stated goals and objectives. This includes immediate retrieval of client records from the records filing for DDAP inspection.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that client file records are present in the filing system in order, so that they are immediately retrievable. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2024.
|
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
|
Observations
Based on a review of client records, the facility failed to ensure partial hospitalization treatment and rehabilitation plans were reviewed and updated at least every thirty days in four of seven applicable client records reviewed.Client #2 was admitted on April 30, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 30, 2024 and the first treatment plan update was due no later than May 30, 2024; however, the update was not completed at the time of the inspection. Client #4 was admitted on April 16, 2024 and was active at the time of the inspection. A treatment plan update was completed on May 1, 2024, and the next update was due no later than June 1, 2024; however, the update was not completed at the time of the inspection. Client #5 was admitted on September 19, 2023 and was discharged on December 14, 2023. A treatment plan update was completed on November 1, 2023, and the next update was due no later than December 1, 2023; however, the update was not completed prior to discharge.Client #6 was admitted on October 18, 2023 and was discharged on January 25, 2024. The individual treatment and rehabilitation plan was completed on November 7, 2023, and the first treatment plan update was due no later than December 7, 2023; however, the update was not completed prior to discharge.This is a repeat citation from the July 14, 2022 and June 27, 2023 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of 709.82(b) Treatment and rehabilitation services by 8/30/2024. Staff participation in this training will be kept in staff training files.
The Clinical Director will review treatment plan completion and due-date status every morning on the Pathways to Recovery Treatment Plan tracker, which is kept in the Clinical Director's office, and will consult staff on a daily basis about treatment plan completions.
The Clinical Director will review treatment plan completion and due-date status at every (e.g. weekly) Clinical Team Meeting using the Pathways to Recovery Treatment Plan tracker, and will consult staff about treatment plan completions during that meeting.
The Clinical Director will review treatment plan completion and due-date status at every (e.g. weekly) Counselor and Intake Coordinator Individual staff meeting, using the Pathways to Recovery Treatment Plan tracker, and will consult staff about their treatment plan completions with clients during that meeting. Compliance with meeting due dates for Treatment Plans with clients on their caseload will be documented on the Counselor's Individual Staff Supervision Notes.
The Clinical Director will report Treatment Plan Completions to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting due dates for Treatment Plans will be documented on The Clinical Director's Individual Staff Supervision Notes.
The Project Director will report Treatment Plan Completions to the PHMC Managing Director of Addiction Services Division during regular (e.g. monthly) Supervision meetings. Compliance with the Program's meeting due dates for Treatment Plans will be documented on The Program Director's Individual Staff Supervision Notes.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that treatment plans are completed in a timely manner and are present in the official client record. The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2024.
|
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to ensure counseling services were being provided according to the individual treatment and rehabilitation plan in seven of seven applicable client records reviewed. Client #1 was admitted on April 23, 2024 and was active at the time of the inspection. The individual treatment plan dated May 1, 2024 and the treatment plan update dated June 1, 2024 specified 1-2 individual counseling services per week. There was no documentation of individual counseling services occurring throughout the treatment episode.Client #2 was admitted on April 30, 2024 and was active at the time of the inspection. The individual treatment plan dated April 30, 2024 specified 1-2 individual counseling services per week. There was no documentation of individual counseling services occurring throughout the treatment episode.Client #4 was admitted on April 16, 2024 and was active at the time of the inspection. The individual treatment plan dated April 16, 2024 and the treatment plan update dated May 1, 2024 specified 1-2 individual counseling services per week. There was no documentation of individual counseling services occurring during the weeks of April 21, 2024 through May 4, 2024, May 12, 2024 through May 18, 2024, and June 2, 2024 through June 8, 2024.Client #5 was admitted on September 19, 2023 and was discharged on December 14, 2023. The individual treatment plan dated October 7, 2023 and the treatment plan update dated November 1, 2023 specified 1-2 individual counseling services per week. There was no documentation of individual counseling services occurring throughout the treatment episode.Client #6 was admitted on October 18, 2023 and was discharged on January 25, 2024. The individual treatment plan dated November 17, 2023 specified 1-2 individual counseling services per week. There was no documentation of individual counseling services occurring during the weeks of October 22, 2023 through November 25, 2023 and December 3, 2023 through December 16, 2023.Client #7 was admitted on August 8, 2023 and was discharged on November 16, 2023. The individual treatment plan dated August 29, 2023 and the treatment plan updates dated September 20, 2023 and October 20, 2023 specified 1-2 individual counseling services per week. There was no documentation of individual counseling services occurring throughout the treatment episode.Client #8 was admitted on September 15, 2023 and was discharged on November 28, 2023. The individual treatment plan dated October 2, 2023 and the treatment plan update dated October 30, 2023 specified 1-2 individual counseling services per week. There was no documentation of individual counseling services occurring throughout the treatment episode.This is a repeat citation from the June 27, 2023 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of 709.82(c) Treatment and rehabilitation services by 8/30/2024. Staff participation in this training will be kept in staff training files.
The Clinical Director will review that counseling services are provided according to the individual treatment and rehabilitation plan using the Pathways to Recovery Client Registry Service (CRS) Electronic Health Record (EHR), at least weekly.
The Clinical Director will review counseling services completion status at every (e.g. weekly) Clinical Team Meeting with the counseling staff.
The Clinical Director will review counseling services completion and due-date status at every (e.g. weekly) Counselor and Intake Coordinator Individual staff meeting, using the CRS EHR. Compliance with meeting counseling services frequencies for clients on their caseload will be documented on the Counselor's Individual Staff Supervision Notes.
The Clinical Director will report counseling services completion to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting frequencies for counseling services will be documented on The Clinical Director's Individual Staff Supervision Notes.
The Project Director will report counseling services completions to the PHMC Managing Director of Addiction Services Division during regular (e.g. monthly) Supervision meetings. Compliance with the Program's meeting due dates for counseling services will be documented on The Program Director's Individual Staff Supervision Notes.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that counseling services are completed in a timely manner according to the treatment plans and are present in the official client record. The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2024.
|
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.
|
Observations
Based on review of client records, the facility failed to ensure clients admitted to the partial hospitalization program received individual counseling at least twice weekly in seven of seven applicable client records reviewed. Client #1 was admitted on April 23, 2024 and was active at the time of the inspection. There was no documentation of individual counseling sessions occurring throughout the treatment episode.Client #2 was admitted on April 30, 2024 and was active at the time of the inspection. There was no documentation of individual counseling sessions occurring throughout the treatment episode.Client #4 was admitted on April 16, 2024 and was active at the time of the inspection. There was no documentation of individual counseling sessions occurring during the weeks of April 21, 2024 through May 4, 2024, May 12, 2024 through May 18, 2024, and June 2, 2024 through June 8, 2024.Client #5 was admitted on September 19, 2023 and was discharged on December 14, 2023. There was no documentation of individual counseling sessions occurring throughout the treatment episode.Client #6 was admitted on October 18, 2023 and was discharged on January 25, 2024. There was no documentation of individual counseling sessions occurring during the weeks of October 22, 2023 through November 25, 2023, and December 3, 2023 through December 16, 2023.Client #7 was admitted on August 8, 2023 and was discharged on November 16, 2023. There was no documentation of individual counseling sessions occurring throughout the treatment episode.Client #8 was admitted on September 15, 2023 and was discharged on November 28, 2023. There was no documentation of individual counseling sessions occurring throughout the treatment episode.This is a repeat citation from the July 14, 2022 and June 27, 2023 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of 709.82(d)(1) Treatment and rehabilitation services by 8/30/2024. Staff participation in this training will be kept in staff training files.
On at least a weekly basis, the Clinical Director will review that individual counseling services are provided to clients according to the 709.82(d)(1) , at least twice weekly, using the Pathways to Recovery Client Registry Service (CRS) Electronic Health Record (EHR).
The Clinical Director will review counseling services completion status at every (e.g. weekly) Clinical Team Meeting with the counseling staff.
The Clinical Director will review counseling services completion and due-date status at every (e.g. weekly) Counselor and Intake Coordinator Individual staff meeting, using the CRS EHR. Compliance with meeting counseling services frequencies for clients on their caseload will be documented on the Counselor's Individual Staff Supervision Notes.
The Clinical Director will report counseling services completion to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting frequencies for counseling services will be documented on The Clinical Director's Individual Staff Supervision Notes.
The Project Director will report counseling services completions to the PHMC Managing Director of Addiction Services Division during regular (e.g. monthly) Supervision meetings. Compliance with the Program's meeting due dates for counseling services will be documented on The Program Director's Individual Staff Supervision Notes.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that counseling services are completed in a timely manner according to 709.82(d)(1) , at least twice weekly, with documentation present in the official client record. The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2024.
|
709.83(a)(11) LICENSURE Client records
709.83. 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.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in three of four applicable client records reviewed.Client #5 was admitted on September 19, 2023 and was discharged on December 14, 2023. There was no documentation of follow-up information at the time of the inspection.Client #6 was admitted on October 18, 2023 and was discharged on January 25, 2024. There was no documentation of follow-up information at the time of the inspection.Client #7 was admitted on August 8, 2023 and was discharged on November 16, 2023. There was no documentation of follow-up information at the time of the inspection.This is a repeat citation from the June 27, 2023 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All follow-up staff and counselor staff will be trained by the Program Director and Clinical Director on the requirements of 709.83(a)(11)Client Records by 8/30/2024. Staff participation in this training will be kept in staff training files.
The Clinical Director will review Client Discharges at every (e.g. weekly) Clinical Team Meeting using reports from the Pathways to Recovery Client Registry Service (CRS) Electronic Health Record (EHR), and will consult follow-up staff about individual following-up with those discharges at that meeting.
The Clinical Director will report follow-up information completion to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting follow-up information will be documented on The Clinical Director's Individual Staff Supervision Notes.
The Project Director will report follow-up information completions to the PHMC Managing Director of Addiction Services Division during regular (e.g. monthly) Supervision meetings. Compliance with the Program's meeting due dates for follow-up information will be documented on The Program Director's Individual Staff Supervision Notes.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that follow-up information is completed in a timely manner according to 709.83(a)(11), with documentation present in the official client record. The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2024. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(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.
|
Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for ensuring the completion of treatment plan updates within the regulatory timeframe were submitted and approved by the Department for the July 14, 2022 and June 27, 2023 annual licensing inspections. Not completing treatment plan updates within the regulatory timeframe was again found to be a deficiency in the June 25, 2024 licensing inspection.Plans of correction for ensuring individual counseling services were provided to partial hospitalization clients at least twice weekly were submitted and approved by the Department for the July 14, 2022 and June 27, 2023 annual licensing inspections. Not providing individual counseling services at least twice weekly was again found to be a deficiency in the June 25, 2024 licensing inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All staff and supervisors responsible for implementing Department approved plans of correction will be trained by the Program Director on the requirements of 709.17(a)(3) by 8/30/2024. Staff participation in this training will be kept in staff training files.
Staff responsible for implementing Department approved plans of correction will report plans of correction implementation status to their Supervisors during regular (e.g. monthly) Supervision meetings. Compliance with meeting plans of correction implementation will be documented on Individual Staff Supervision Notes.
Supervisors will report plans of correction implementation status to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting plans of correction implementation will be documented on The Supervisors' Individual Staff Supervision Notes.
The Project Director will report plan of correction implementation status to the PHMC Managing Director of Addiction Services Division during regular (e.g. monthly) Supervision meetings. Compliance with the Program's meeting plans of correction will be documented on The Program Director's Individual Staff Supervision Notes.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that plans of correction approved by the Department are being implemented according to 709.17(a)(3). The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2024.
|