INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 25, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ADAPPT Outpatient Treatment 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the January 2020 through January 2021 fire drill log, the facility failed to identify, on the fire drill log, the number of persons in the facility at the time of the drill during each fire drill conducted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will revise the Fire Drill Record to include the date, time, the amount of time for evacuation, exit route, the number of persons in the facility and/or problems with drill. Facility Director will train all staff on revised form no later than 3/31/21. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in three of seven client records reviewed.
Client # 2 was admitted on March 11, 2020 and was discharged on October 30, 2020. The written procedure manual stated that the comprehensive treatment plan would be completed within 60 days of admission. Client # 2's comprehensive treatment plan should have been completed no later than May 11, 2020; however, the plan was completed on May 21, 2020.
Client # 3 was admitted on May 28, 2020 and was discharged on December 24, 2020. The written procedure manual stated that the comprehensive treatment plan will be completed within 60 days of admission. Client # 3's comprehensive treatment plan should have been completed no later than July 28, 2020; however, the plan was completed on August 28, 2020.
Client # 5 was admitted on June 2, 2020 and was still active at time of inspection. The written procedure manual stated that the comprehensive treatment plan will be completed within 60 days of admission. Client # 5's comprehensive treatment plan should have been completed no later than August 2, 2020; however, the plan was completed on August 11, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will revise Policy & Procedure to indicate treatment plan reviews every 60 days, in accordance with DDAP policy. Facility Director and counselors will create a check list to ensure the treatment plans are updated according to that policy. Facility Director will conduct monthly chart audits to ensure compliance. Facility Director will train counselors by 3/31/21.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent was offered to the client in three of seven client records reviewed.
Client # 1 was admitted on March 11, 2020 and discharged on November 16, 2020. Two release of information forms to a government agency and an outside individual were signed and dated by the client on March 16, 2020, but both forms did not indicate that a copy was offered to the client.
Client # 6 was admitted on June 12, 2020 and was still active at the time of inspection. Two release of information forms to a government agency and an outside individual were signed and dated by the client on June 12, 2020, but both forms did not indicate that a copy was offered to the client.
Client # 7 was admitted on June 10, 2020 and was still active at the time of inspection. Two release of information forms to a government agency and an outside individual were signed and dated by the client on June 10, 2020, but both forms did not indicate that a copy was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will retrain staff on correct procedure for offering to clients a copy of consents, an documenting their acceptance or refusal of it. Staff will be retrained by 3/31/21 and Facility Director will conduct monthly chart audits to ensure compliance throughout the next year. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in the client's comprehensive treatment plan in three of seven client records reviewed.
Client # 4 was admitted on July 23, 2020 and discharged on January 29, 2021. The comprehensive treatment plan was completed on August 18, 2020; however, the plan did not include type and frequency of treatment and rehabilitation services.
Client # 5 was admitted on June 2, 2020 and was still active at the time of inspection. The comprehensive treatment plan was completed on August 11, 2020; however, the plan did not include type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on June 12, 2020 and was still active at the time of inspection. The comprehensive treatment plan was completed on July 10, 2020; however, the plan did not include type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will review the treatment plans with counselors to include updates on the frequency of individual sessions when completing the treatment plan updates by 3/31/21. Facility Director will conduct monthly chart audits to ensure compliance. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services in the client's individual treatment plan in three of seven client records reviewed.
Client # 2 was admitted on March 11, 2020 and was discharged on October 30, 2020. The comprehensive treatment plan was completed on May 21, 2020; however, the plan did not include proposed type of support services.
Client # 4 was admitted on July 23, 2020 and discharged on January 29, 2021. The comprehensive treatment plan was completed on August 18, 2020; however, the plan did not include proposed type of support services.
Client # 5 was admitted on June 2, 2020 and was still active at the time of inspection. The comprehensive treatment plan was completed on August 11, 2020; however, the plan did not include proposed type of support services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will review the treatment plans with counselors to include updates on the supportive services when completing the treatment plan updates by 3/31/21. Facility Director will conduct monthly chart audits to ensure compliance. |
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 a review of client records, the facility failed to provide treatment plan updates within the regulatory timeframe in three of seven client records reviewed.
Client # 2 was admitted on March 11, 2020 and was discharged on October 30, 2020. The comprehensive treatment plan was completed on May 21, 2020, and the first update was due no later than July 21, 2020; however, the update was not completed prior to discharge.
Client # 5 was admitted on June 2, 2020 and was still active at time of inspection. The comprehensive treatment plan was completed August 2, 2020, and the first update was due no later than October 2, 2020; however, the update was completed on October 28, 2020. Additionally, a treatment plan update was completed on November 11, 2020 and the next update was to be completed by January 11, 2021; however, the update was not completed at the time of inspection.
Client #6 was admitted on June 12, 2020 and was still active at the time of inspection. The comprehensive treatment plan was completed on July 10, 2020, and the first update was due no later than September 10, 2020; however, the update was completed on November 5, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will revise Policy & Procedure to indicate treatment plan reviews every 60 days, in accordance with DDAP policy. Facility Director and counselors will create a check list to ensure the treatment plans are updated according to that policy. Facility Director will conduct monthly chart audits to ensure compliance. Facility Director will train counselors by 3/31/21. |
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 client records, the facility failed to a maintain a complete client record on an individual, which is to include a discharge summary, in three of four applicable client records reviewed.
Client # 1 was admitted on March 11, 2020 and was discharged on November 16, 2020. There was no documentation of a completed discharge summary in the client record at the time of the inspection.
Client # 2 was admitted on March 11, 2020 and was discharged on October 30, 2020. There was no documentation of a completed discharge summary in the client record at the time of the inspection.
Client # 4 was admitted on July 23, 2020 and was discharged on January 29, 2021. There was no documentation of a completed discharge summary in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will retrain counselors on Discharge Policy by 3/31/21. Facility Director and Counselors will create a checklist to ensure timely completion of discharge summaries. Facility Director will conduct weekly chart audits to ensure compliance. |
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 client records, the facility failed to a maintain a complete client record on an individual, which is to include follow-up information, in two of three applicable client records reviewed.
Client # 1 was admitted on March 11, 2020 and was discharged on November 16, 2020. There was no documentation of follow-up information in the client record at the time of the inspection.
Client # 2 was admitted on March 11, 2020 and was discharged on October 30, 2020. There was no documentation of follow-up information in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will retrain counselors on Post-Completion Contact Policy by 3/31/21. Facility Director and Counselors will create a checklist to ensure clients are contacted in accordance with this policy. Facility Director will conduct monthly chart audits to ensure compliance. |