INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24 & 29, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Caring Healthcare Network LLC 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 a review of fire drill logs from June 2022 - February 2023, the facility failed to conduct unannounced fire drills at least once a month. Documentation showed that the drills were announced.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The MAT Project Director will collaborate with the Practice Manager to create a fire drill log to include unannounced fire drills utilizing the Unannounced Monthly Fire Evaluation Checklist to document monthly fire drills at the facility. The Front Office Supervisor will ensure that monthly fire drills are unannounced as they are scheduled and facilitated. Documentation of unannounced fire drills will be filed in a binder and kept in the office of the MAT Project Director. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from June 2022 - February 2023, the facility failed to utilize alternate exit routes during drills. During all drills reviewed, except for October 2022, the facility documented that all exits were used during drills.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MAT Project Director will collaborate with the Practice Manager to create a fire drill log to include documentation of the exit used for the evacuation based on the location of the fire. The Front Office Supervisor will ensure that an alterative exit is utilized for each monthly fire drill as they are conducted. This will be documented utilizing the Unannounced Monthly Fire Evaluation Checklist. Documentation of the exit used for monthly evacuations will be filed in a binder and kept in the office of the MAT Project Director.
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709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
Based on the review of the facility's policy and procedures manual, the facility failed to have written policies and procedures to include the utilization of volunteers.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MAT Project Director will collaborate with the Practice Manager and the Human Resources Specialist to ensure that the Updated Employee Handbook for The Caring Healthcare Network will include written project personal and procedures that specifically include utilization of volunteers. The Updated Employee Handbook for the project will be reviewed and approved by the governing body/ CEO and Owner of The Caring Healthcare Network. Documentation of the facility's policy outlining the utilization of volunteers will be added to the facility's policy and procedures manual that is kept in the office of the MAT Project Director. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in six out of seven client records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #1 was admitted on October 26, 2022 and was still active at the time of the inspection.
Client #2 was admitted on September 28, 2022 and discharged on February 13, 2023.
Client #3 was admitted on November 17, 2022 and was still active at the time of the inspection.
Client #4 was admitted on November 7, 2022 and was still active at the time of the inspection.
Client #5 was admitted on August 4, 2022 and discharged on October 10, 2022.
Client #7 was admitted on January 16, 2023 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MAT Project Director will ensure that all current clients sign a new release for the discloser of information for the funding source and this will be corrected for all new clients moving forward. The signed consent for release of information will be uploaded into the chart in the electronic health record (EHR) to be utilized for billing purposes.
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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.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in two out of seven records reviewed. The consent forms did not include to the name of the person, agency or organization to whom disclosure may be made.
Client #3 was admitted on November 17, 2022 and was still active at the time of the inspection. The consent form was dated November 17, 2022.
Client #7 was admitted on January 16, 2023 and was still active at the time of the inspection. The consent form was dated January 30, 2023.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MAT Project Director will ensure that all current clients sign a new release for the discloser of information that will include the name of the person and the agency or organization to whom the disclosure may be made. This will be corrected for all new clients moving forward. The signed consent for release of information will be uploaded into the chart in the electronic health record (EHR) to be utilized for billing purposes.
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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.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in four out of seven records reviewed.
Client #1 was admitted on October 26, 2022 and was still active at the time of the inspection. A consent form to the funding source dated October 26, 2022 had "other" checked for information to be disclosed without specifying what additional information was permitted to be released.
Client #3 was admitted on November 17, 2022 and was still active at the time of the inspection. Two consent forms to the funding source and an undocumented person, agency or organization dated October 26, 2022 had "other" checked for information to be disclosed without specifying what additional information was permitted to be released.
Client #4 was admitted on November 7, 2022 and was still active at the time of the inspection. A consent form to a medical facility dated November 7, 2022 had "other" checked for information to be disclosed without specifying what additional information was permitted to be released.
Client #7 was admitted on January 16, 2023 and was still active at the time of the inspection. A consent form to an undocumented person, agency or organization dated January 30, 2023 did not specify what information was permitted to be released.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MAT Project Director will ensure that all current clients sign a new release of information that is fully completed correctly. Project director will review the releases with the client to ensure that every ROI is correct and if other is checked, the specific information to be disclosed will specify what additional information is permitted to be released. This will be corrected on a releases of information moving forward. The signed consent for release of information will be uploaded into the chart in the electronic health record (EHR).
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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.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in six out of seven records reviewed. The consent forms did not include a purpose of disclosure.
Client #1 was admitted on October 26, 2022 and was still active at the time of the inspection. The consent form was dated October 26, 2022 to the funding source.
Client #2 was admitted on September 28, 2022 and was discharged on February 13, 2023. The consent form was dated September 28, 2022 to an emergency contact.
Client #4 was admitted on November 7, 2022 and was still active at the time of the inspection. The consent form was dated February 12, 2023 to a funding source.
Client #5 was admitted on August 4, 2022 and discharged on October 10, 2022. The consent form was dated September 16, 2022 to an employee assistance program.
Client #6 was admitted on September 19, 2022 and discharged on January 3, 2023. The consent form was dated October 12, 2022 to an emergency contact.
Client #7 was admitted on January 16, 2023 and was still active at the time of the inspection. The consent form was dated January 30, 2023 and did not list to whom the disclosure could be made.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MAT Project Director will ensure that all current clients sign a new release of information that includes a purpose of disclosure. Project director will review the releases with the client to ensure that every ROI is complete with the correct information and that purpose of disclosure or reason for the release is filled in correctly. The signed consent for release of information will be uploaded into the chart in the electronic health record (EHR). |
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 document that a copy a client consent form shall be offered to the client in six out of seven client records reviewed.
Client #1 was admitted on October 26, 2022 and was still active at the time of the inspection. Three consent forms dated October 26, 2022 were to a healthcare agency, emergency contact and a funding source.
Client #2 was admitted on September 28, 2022 and discharged on February 13, 2023. Two consent forms dated September 28, 2022 were to an emergency contact and a social service agency.
Client #3 was admitted on November 17, 2022 and was still active at the time of the inspection. Two consent forms dated November 17, 2022 were to a funding source and an emergency contact. An additional consent form dated November 17, 2022 did not list to whom disclosures may be made.
Client #4 was admitted on November 7, 2022 and was still active at the time of the inspection. Four consent forms dated November 7, 2022 were to two medical facilities, a funding source and an emergency contact.
Client #6 was admitted on September 19, 2022 and discharged on January 3, 2023. Two consent forms dated September 19, 2022 and September 21, 2022 were to funding sources.
Client #7 was admitted on January 16, 2023 and was still active at the time of the inspection. A consent form dated January 30, 2023 did not list to whom disclosures may be made. A second consent form dated January 16, 2023 was to an emergency contact.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MAT Project Director will collaborate with the Front Office Supervisor will create new releases of information forms to be used for the MAT program. Releases of information will include an area that states that each patient has been offered a copy of the consent and client will have an area to initial that they accepted or declined. The updated release of information for the project will be reviewed by the company's Project Manager and CFO for approval to be used in the program. As the updated release of information have been approved, all current clients will sign new releases and the updated releases will be used moving forward. Project director will review each release with the client to ensure that they are completed correctly. The signed consent for releases of information will be uploaded into the chart in the electronic health record (EHR). |
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 a review of client records, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in seven out of seven records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MAT Project Director will collaborate with the Front Office Supervisor will add section 709.30. Client rights to the Notice Of Privacy Practices that each new patient receives at intake. The updated Notice Of Privacy Practices will be reviewed by the company's Project Manager and CFO for approval to be used in the program. As the updated Notice Of Privacy Practices has been approved, all current clients will sign the Acknowledgement of Receipt. This is part of the MAT intake. The signed Acknowledgement of Receipt of the Notice of Privy Practices and Client Rights will be uploaded into the chart in the electronic health record (EHR). |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to orient the client to the project which shall include familiarization with hours of operation in seven out of seven records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MAT Project Director will complete new patient orientation within the first 60 days of treatment. Orientation will include the project policies, hours of operation, the number to call after hours, services provided, rules of the facility, fee schedule and criteria for involuntary discharge. The Counselor and the client will also review appropriate and expected behavior at the facility. The client will be given an overview of program goals and objectives of the program regarding their care. The rules of the program will be described, along with the obligations and rights of clients. Program operations are described, including details of what the client can expect to incur in the way of charges and financial obligations, policies regarding insurance and hours of operation, and services. The 2.5 hour counseling requirement will be reviewed as well as the importance of completing all required counseling time each month. Orientation will be provided to the client via individual session and documented in the progress note. Client orientation will be reviewed with each current client and documented in an individual progress note. Documentation of orientation will be in the client chart in the electronic health record (EHR). |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to orient the client to the project which shall include familiarization with the fee schedule in seven out of seven records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MAT Project Director will complete new patient orientation within the first 60 days of treatment. Orientation will include the project policies, hours of operation, the number to call after hours, services provided, rules of the facility, fee schedule and criteria for involuntary discharge. The Counselor and the client will also review appropriate and expected behavior at the facility. The client will be given an overview of program goals and objectives of the program regarding their care. The rules of the program will be described, along with the obligations and rights of clients. Program operations are described, including details of what the client can expect to incur in the way of charges and financial obligations, policies regarding insurance and hours of operation, and services. The 2.5 hour counseling requirement will be reviewed as well as the importance of completing all required counseling time each month. Orientation will be provided to the client via individual session and documented in the progress note. Client orientation will be reviewed with each current client and documented in an individual progress note. Documentation of orientation will be in the client chart in the electronic health record (EHR). |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to orient the client to the project which shall include familiarization with services provided in seven out of seven records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MAT Project Director will complete new patient orientation within the first 60 days of treatment. Orientation will include the project policies, hours of operation, the number to call after hours, services provided, rules of the facility, fee schedule and criteria for involuntary discharge. The Counselor and the client will also review appropriate and expected behavior at the facility. The client will be given an overview of program goals and objectives of the program regarding their care. The rules of the program will be described, along with the obligations and rights of clients. Program operations are described, including details of what the client can expect to incur in the way of charges and financial obligations, policies regarding insurance and hours of operation, and services. The 2.5 hour counseling requirement will be reviewed as well as the importance of completing all required counseling time each month. Orientation will be provided to the client via individual session and documented in the progress note. Client orientation will be reviewed with each current client and documented in an individual progress note. Documentation of orientation will be in the client chart in the electronic health record (EHR). |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations within the timeframe outlined in the facility's policy and procedures manual in four out of six applicable records reviewed. The policy and procedures manual states case consultants should occur every three months.
Client #1 was admitted on October 26, 2022 and was still active at the time of the inspection. A case consultation was due on January 26, 2022; however, it was completed on February 27, 2023.
Client #3 was admitted on November 17, 2022 and was still active at the time of the inspection. A case consultation was due on February 17, 2023; however, there was no documentation of a case consultation in the record.
Client #4 was admitted on November 7, 2022 and was still active at the time of the inspection. A case consultation was due on February 7, 2023; however, it was completed on February 27, 2023.
Client #6 as admitted on September 19, 2022 and discharged on January 3, 2023. A case consultation was due on December 19, 2022; however, it was completed on December 23, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MAT Project Director will complete a case consultation during the intake, including a brief synopsis of the client's medical, social, personal, mental health, and substance use histories; other services the client may be interested in, including medication-assisted treatment; and anything else of importance. Case Consultation will take place every three months for the first year of the client's treatment. The MAT Project Director will monitor all case consultation to ensure that they are completed by the identified date and ensure that each case consultation is completed within thirty days of the last one. Documentation of case consultation will be in the client chart in the electronic health record (EHR).
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