INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on October 10, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MCP/Caring Together 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.A storage cabinet, located in the childcare area, next to a baby bouncer, had a cabinet door that was broken and hanging loose, which allowed for possible safety hazard.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director or designee tour the facility weekly and note issues that present as a safety issue. Program Director or designee will utilize the facility log to manage repair needs. All staff members have been directed to report safety hazards to the Program Director or designee, who will monitor the issue for completion. |
711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance 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.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for developing and documenting an individual's treatment and rehabilitation plan was submitted and approved by the Department for the April 8, 2021 and April 20, 2022, annual licensing inspections, November 2, 2022 provisional licensing inspection, and March 29, 2023 annual licensing inspection. Developing and documenting an individual's treatment and rehabilitation plan was again found to be a deficiency in the October 10, 2023, provisional licensing inspection.A plan of correction for ensuring that a copy of a client consent was offered to the client was submitted and approved by the Department for the April 8, 2021, April 20, 2022 annual licensing inspection, November 2, 2022 provisional licensing inspection, and March 29, 2023 annual licensing inspection. Ensuring that a copy of a client consent was offered to the client was again found to be a deficiency in the October 10, 2023, provisional licensing inspection.This is a repeat citation from the April 20, 2022, November 2, 2022, and March 29, 2023 licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This ongoing issue continues to be addressed in trainings. The Program Director met with the Electronic Medical Records team to ensure that the treatment plans references the option of a participant being offed a copy of the document. This offering of the treatment plans is on the paper version and Program Director will meet with each therapist individually to ensure that they understand the importance of completing this task. This will be monitored by Program Director when reviewing and signing off on the document.
The Program Director will provide ongoing treatment planning training for the staff. Monthly group training will occur starting in January 2024. Program Director will provide copies of appropriate treatment plans for staff to use as a reference. The training will also include the incorporation of documenting progress/lack of progress.
The Program Director will continue to provide training throughout the year. The Program Director will meet with each therapist individually to ensure that they understand the concept of successfully completing treatment plans.
The Program Director will develop a spreadsheet for each therapist, noting the due dates for each treatment plan. The spreadsheet will contain the key elements of the spreadsheet to ensure that the documentation is appropriate. The Program Director will monitor the spreadsheet monthly with the therapist. The Program Director will initiate Monthly Treatment Planning sessions with each therapist. Training to address the specifics of the treatment plans will begin in December of 2023 and the monthly sessions will begin January 2024. The Program Director will provide additional training for therapists that appear to struggle with successfully completing treatment plans. Program Director will also ensure that the treatment plans in the EMR are sufficient and are designed to address the necessary elements. Program Director will will closely monitor the spreadsheet and training needs. |
711.92(a)(3) LICENSURE Mngt of Treatment Services
711.92. Treatment and rehabilitation services.
(a) The project 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 development, approval and ongoing management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients in one of one applicable client records reviewed.The policy and procedure manual stated that the individual treatment and rehabilitation plan will be completed within a month of admission.Client #4 was admitted on June 6, 2023 and was active at the time of inspection. The individual treatment plan was due no later than July 6, 2023; however, the plan was completed on October 6, 2023.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will continue to provide training for the timeliness of Treatment Plans. Program Director or designee will meet with each therapist individually to ensure that there is a clear understanding of the significance of developing the treatment plan in accordance with the policy and procedure manual. In the event that the treatment plan cannot be completed timely, the Program Director will ensure that there is clear and concise documentation in explaining the delay.
Going forward, all medical records for new participants will be monitored by Program Director or designee after the 15th day in treatment. At that time, if the treatment plan is not completed the Program Director will meet with the therapist. The therapist will need to present a plan for ensuring that the document will be completed per the policy. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to develop and document the individual's treatment and rehabilitation plan with the client in three of four applicable client records reviewed. Client #5 was admitted on June 8, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was not developed at the time of inspection. Client #6 was admitted on June 8, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was not developed at the time of inspection. Client #7 was admitted on June 13, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was not developed at the time of inspection. This is a repeat citation from the April 8, 2021, April 20, 2022, November 2, 2022 and March 29, 2023 licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will continue to train therapist regarding the significance of developing the treatment plan timely and with the participant. Program Director or designee will meet with all therapists individually to ensure that there is a clear understanding of the policy.
In the event that a participant is not engaging in the individual session, therapist will notify the Program Director. Program Director will provide assistance in encouraging the participant in appropriate engagement. Therapist will note in the record reasons for delay in the timeliness of developing treatment plan with participant. |
711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) 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 properly document the type and frequency of treatment and rehabilitation services in the client's individual treatment and rehabilitation plan in one of one applicable client records reviewed.Client #4 was admitted on June 6, 2023 and active at time of inspection. The individual treatment and rehabilitation plan completed on October 6, 2023, did not include type and frequency of treatment and rehabilitation services. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director (PD) will continue to train therapists in the importance properly documenting type and frequency of services on the treatment plan. Program Director has met with the EMR Development Team to ensure that the documents has an area to note type and frequency of services.
Immediately after approval of this POC, Program Director will have individual Treatment Plan Sessions with each therapist. At the session, the PD will closely review the developed document with the therapist to ensure that there is a clear understanding of the procedure. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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 assure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in one of one applicable client records reviewed.Client #8 was admitted on December 22, 2022 and was discharged on September 27, 2023. A treatment plan update was completed on March 10, 2023, and the next update was due no later than May 10, 2023; however, the update was not completed prior to discharge.This is a repeat citation from the March 29, 2023 licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director (PD) will continue to train on this issue. Program Director is requesting that the organization hire a Clinical Supervisor to focus on supervision of records and training staff.
Participants are often discharged for lack of engagement. Staff are being informed that they must complete a treatment plan update at least every sixty days regardless of participants' active engagement. The treatment plan will note that participant was not engaged during this period. Program Director will monitor for notation of this information in reviewing treatment plans. |
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in one of one applicable client records reviewed. Client #8 was admitted on December 22, 2022 and was discharged on September 27, 2023. A treatment plan update dated March 10, 2023, specified weekly individual counseling services. There was no documentation, in the client record, of individual counseling services occurring the weeks of May 28, 2023 - June 10, 2023, June 18, 2023 - July 8, 2023, July 30, 2023 - August 12, 2023, and August 20, 2023 - September 2, 2023. This is a repeat citation from the March 29, 2023 licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will continue to train the staff regarding this issue. The Program Director will develop a "Lack of Engagement Form" that will be completed by the therapist and entered in the EMR. The form will have options for noting the reason for lack of engagement. This use of this form will be monitored by Program Director. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document the aftercare plan in one of one applicable client records reviewed.Client #8 was admitted December 22, 2022 and discharged on September 27, 2023. There was no documentation of an aftercare plan, in the client record, at the time of inspection.This is a repeat citation from the March 29, 2023 licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An After Care document has been developed and training with the staff has occurred. The Program Director will host another training for the use of the document. The Program Director will monitor the completion of the aftercare plan when reviewing the discharge summary. Additional training will be facilitated in group and individual format by the Program Director. |
711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
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Observations
Based on the physical plant inspection conducted, the facility failed to maintain confidentiality of client identity and records. There were several client charts and loose documents located in bins and on shelves in two counselor offices. There were piles of client documents located throughout the peer specialist office.This is a repeat citation from the March 29, 2023 licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has counseled staff regarding the importance of confidentiality of records. Staff was directed to file loose documents timely to avoid confidentiality issues.
Small file cabinets with locks will be purchased for counselors to store documents in their offices. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client on release of information form in one of seven applicable client records reviewed. Client #4 was admitted on June 6, 2023 and was active at the time of inspection. There was a release of information form to a pharmacy that was signed and dated by the client on June 6, 2023; however, there was no documentation that a copy of the form was offered to the client. This is a repeat citation from the April 8, 2021, April 20, 2022, November 2, 2022 and March 29, 2023 licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
This ongoing issue is continuously addressed during trainings and individually with therapists in supervision sessions.
The Program Director reviews the intake package after completion. I will ensure that all consents are noted for offering a copy of the consent. We are considering reviewing the intake packages including the consents at the time of the intake. This may be useful to ensuring that the participant is a copy of documents are offered and documented. |
711.95(b) LICENSURE Efficient Retrieval of Data
711.95. Uniform Data Collection System.
(b) A data collection system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
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Observations
Based on an administrative review, the facility failed to develop a data collection system that allows for the efficient retrieval of data needed to measure the project's performance.The facility was unable to produce a client record in an efficient manner. The DDAP representative requested 9 client records and the facility was able to provide 8 of the client records by the end of the inspection. The facility was unable to locate a client record that was admitted since the previous inspection. This is a repeat citation from the March 29, 2023 licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program has transitioned to an Electronic Medical Record. Development of documents in the EMR are ongoing. The intake documents, including most of the consents are not electronic at this time. Therefore, participants records are partially paper and partially electronic, with the goal of complete electronic records in the future.
Poor filing presented an issue in locating records. Program Director has made changes for filing records and documents in the records. Going forward a select few staff will be responsible for filing and retrieving records.
The Program Director will continue to work with the Clinical Applications Team in the development of a comprehensive EMR. |