INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 31, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, PA Treatment and Healing 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #5, whom was hired as a counselor on June 15, 2020, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience to be a counselor.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of inspection it was noted that employee #5 was 5 days short of one year's clinical experience for the position of counselor upon hire. This citation was addressed in reviewing the requirements for the position of counselor. It is the facilities Director's responsibility to review the experience of all staff. Upon hire the employees experience will be examined, if they are under the 1 year requirement of clinical experience they will be hired as an assistant counselor. It will then be the responsibility of the facilities director or clinical supervisor to supervise the assistant counselor until they reach the required experience that DDAP requires. This policy is in effect on September 1 2020. |
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.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form on August 31, 2020, the facility failed to ensure that employee #2 received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #2 was hired as a counselor on February 24, 2019 and was due to have the communicable disease trainings no later than February 24, 2020. The employee completed the TB/STD training on February 13, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency was examined during the inspection on August 31 2020. It was revealed that the required trainings were not completed within the one year of employment. The reason for this deficiency was due to a limited amount of DDAP trainings offered during the 2019 training cycle. However, after further discussion it was noted that other opportunities were available from other organizations recognized by DDAP as enough to comply of DDAP regulations. Therefore, it is the responsibility of the Facilities Director to educate all staff of the required trainings that must be completed within the first year of hire. It is the responsibility of each staff member to search and attain approval from the facilities Director to attend these trainings. The Facilities Director will then place the certificate of competition into the employees file. This policy is in effect on September 1 2020. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical site inspection on August 31, 2020, it was observed that the facility failed to ensure privacy so that counseling session cannot be seen or heard outside the counseling room.
1) Downstairs group room has two doors with glass window inserts which are not covered.
2) Downstairs group room was observed to have both doors open to the hallway during a group session, in which voices could be heard outside the group room.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of the onsite inspection it was noted that the Downstairs group room did not adequately provide confidentiality to those individuals who attended the group sessions. This was a result of the Covid 19 pandemic , in which this group room was being utilized to assure sanitation and social distancing requirements by the Pa Department of health and CDC standards. The deficiency was corrected by educating staff that it is their responsibility to assure that all doors are closed during any counseling sessions. The facilities director then covered the glass panels to assure that confidentiality was provided for those attending groups counseling sessions. This policy was in effect on September 1 2020 |
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
A review of the March 2020 through June 2020 fire drill logs was conducted during the onsite inspection on August 31, 2020. The facility failed to include the amount of time it took to evacuate, problems encountered and whether the fire alarm of smoke detector was operational at the time of the drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This Citation was the result of Facilities Director who instituted a fire drill Policy to comply with the DDAP regs on March 1, 2020. In that the Facilities Director or other appointed staff will oversee and conduct random unannounced Fire drills Monthly. A log of the fire drill containing time location of drill and number of attendees , the amount of time it took to evacuate, problems encountered and whether the fire alarm of smoke detector was operational at the time of the drill will be maintained in the facilities director's office. The Facilities director corrected the errors and will be responsible to maintain the updated information. This policy is in effect on September 1 2020. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
A review of the March 2020 through June 2020 fire drill logs was conducted during the onsite inspection on August 31, 2020. The facility failed to document if the fire alarm or smoke detector was set off during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This Citation was the result of Facilities Director who instituted a fire drill Policy to comply with the DDAP regs on March 1, 2020. In that the Facilities Director or other appointed staff will oversee and conduct random unannounced Fire drills Monthly. A log of the fire drill containing time location of drill and number of attendees , the amount of time it took to evacuate, problems encountered and whether the fire alarm of smoke detector was operational and set off at the time of the drill will be maintained in the facilities director's office. The Facilities director corrected the errors and will be responsible to maintain the updated information. This policy is in effect on September 1 2020. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the policy and procedures manual on August 31, 2020, the facility failed to show documentation that the project director annually updated and signed the manual.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of inspection it was reviewed that the project director did not sign the annually updated policies and procedures manual. It is the responsibility of the CEO and the Project director to review and sign the Policies and Procedures manual on a yearly basis.It is also the project directors who will review and sign to ensure that this citation does not occur again . This policy was in effect on September 1 2020 |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical site inspection, conducted on August 31, 2020, the facility failed to ensure that all hard copy client records were kept in locked storage containers and that there was no ability of unauthorized persons to gain access to such records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency was noted during the onsite inspection of August 31 2020. It was noted that the file room door was not locked at the time of inspection and therefore did note adequately prevent unauthorized persons to gain access to client records. The facilities director instructed all staff to make sure that the door to the file room is always locked. The facilities director also provided keys to all staff for the file room to assure the security of all client files. The facilities director and the office manager will check daily to make sure this policy is observed. This policy was in effect on September 1 2020. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on the review of client records on August 31, 2020, the facility failed to document an informed and voluntary consent to release information form prior to releasing information in client records #1 and 5.
Client #1 was admitted on June 10, 2020 and was still active at the time of the inspection. There was no consent to release information form for the funding source. According to the facility staff, contact and billing had occurred with the funding source.
Client #5 was admitted on January 15, 2020 and discharged on July 14, 2020. A letter was sent to a government agency on July 14, 2020 without a signed release of information form.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 5, 2019 annual licensing inspection and March 11, 2020 provisional licensing inspection.
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Plan of Correction
This citation was addressed to all staff. Afterword's a new release was filled out with the appropriate information for client #1. However due to client #5 being discharged a new release could not be attained. It was revealed during the Audit of 9/8/19 that the chart audits were not being performed in a timely manner. The Facilities director has implemented a new policy on 3/15/2020 in which the Director will oversee all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit.. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete Releases and the specific information to be released per the type of release signed. This oversite was in part due to the inconsistent attendance considering the Covid 19 Pandemic emergency declaration. The Policy was continuing to be implemented on September 1 2020 . |
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 on August 31, 2020, the facility failed to identify what specific information to be disclosed on informed and voluntary consent to release information forms in client record # ' s 2 and 3.
Client #2 was admitted on May 5, 2020 and was still active at the time of the inspection. A consent to release information form to a family member, dated May 5, 2020, indicated " other " information could be released but did not list what specific additional information could be released.
Client #3 was admitted on May 18, 2020 and was still active at the time of the inspection. A consent to release information form to a family member, dated May 18, 2020, indicated " other " information could be released but did not list what specific additional information could be released.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 5, 2019 annual licensing inspection and the March 11, 2020 provisional licensing inspection.
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Plan of Correction
This citation was addressed with all staff and educated on the procedures of completing all forms properly . The clinicians were instructed to have the clients fill in the missing information upon their next session. It was revealed during the Audit of 9/8/19 that the chart audits were not being performed in a timely manner. The new Facilities director has implemented a new policy on 3/15/2020 in which the Director will oversee all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete Releases and the specific information to be released per the type of release signed. This policy was continuing to be implemented on September 1 2020. |
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 on August 31, 2020, the facility failed to properly document the purpose of the disclosure on the informed and voluntary consent to release information form in client record #6.
Client #6 was admitted on November 18, 2019 and discharged on July 28, 2020. A consent to release information form, dated July 28, 2020, to a government agency did not list the purpose of disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This citation was addressed with all staff and educated on the procedures of completing all forms properly. The staff was also educated by the Facilities director to properly document the purpose of the disclosure to the agency that has been consented. The new Facilities director has implemented a new policy on 3/15/2020 in which the Director will oversee all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete Releases and the specific information to be released per the type of release signed. This policy was continuing to be implemented on September 1 2020. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records on August 31, 2020, the facility failed to properly document an expiration date on the informed and voluntary consent to release information forms in client record #1 and 3.
Client #1 was admitted on June 10, 2020 and was still active at the time of the inspection. There was a consent to release information form, dated June 20, 2020, to a laboratory that was missing the expiration information.
Client #3 was admitted on May 18, 2020 and was still active at the time of the inspection. There was a consent to release information form, dated May 18, 2020, to a laboratory that was missing the expiration information.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 5, 2019 annual licensing inspection and the March 11, 2020 provisional licensing inspection.
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Plan of Correction
This citation was addressed with all staff and educated on the procedures of completing all forms properly. The clinicians were instructed to have the clients fill in the missing information in regard to the expiration of the information to be released upon their next session. It was revealed during the Audit of 9/8/19 that the chart audits were not being performed in a timely manner. The new Facilities director has implemented a new policy on 3/15/2020 in which the Director will oversee all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete Releases and the specific information to be released per the type of release signed. This policy was continuing to be implemented on September 1 2020. |
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 the review of client records on August 31, 2020, the facility failed to properly document if the client was offered a copy of the informed and voluntary consent to release information forms in client record #3.
Client #3 was admitted on May 18, 2020 and was still active at the time of the inspection. There were two consent to release information forms in the client ' s file that were missing documentation that the client was offered a copy of the form. The forms were to a laboratory and a family member.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This citation was addressed with all staff and educated on the procedures of completing all forms properly. The clinicians were instructed to have the clients initial all documents of whether they wish to have a copy. The facilities director also reviewed the entire intake packet to assure they offered a spot for such consideration. It was revealed during the Audit of 9/8/19 that the chart audits were not being performed in a timely manner. The new Facilities director has implemented a new policy on 3/15/2020 in which the Director will oversee all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete Releases and the specific information to be released per the type of release signed. This policy was continuing to be implemented on September 1 2020. |
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.
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Observations
Based on a review of the policy and procedures manual and client rights notification documentation on August 31, 2020, the project failed to include all parts of the client rights regulation. The project failed to include that a client may not be discriminated against based on creed, sex, color and national origin.
These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the September 5, 2019 annual licensing inspection and the March 11, 2020 provisional licensing inspection.
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Plan of Correction
It was noted that the director in error presented on August 31 2020 at the time of inspection an old version of the PNP . This citation has been corrected in that corrections to both the policies and procedures manual and the Clients rights documentation in the active client charts have been updated as of September 1 2020, to state " " 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." It is the responsibility of the Program director and the Facilities director to assure that this policy is corrected and updated in all client files . This policy is in full effect as of September 1 2020. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records on August 31, 2020, the facility failed to notify the client, in writing, of the facility's reason to involuntarily terminate the client in one applicable record reviewed.
Client #4 was admitted on June 1, 2020 and discharged on July 13, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facilities director educated all staff on the requirements for documentation. This error could not be addressed due to the client has been discharged. The discharge paperwork and the Case consult must define the reasons for termination. The client will be given a written notice explaining the reason for termination. The facilities director before signing any discharge paperwork will review the reasons for termination and assure, they are clearly defined. This policy is in effect September 1 2020 |
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 on August 31, 2020, the facility failed to document treatment plan updated within the regulatory timeframe in client # ' s 3 and 7.
Client #3 was admitted on May 18, 2020 and was still active at the time of the inspection. A comprehensive treatment plan was completed on June 2, 2020 and an update was due no later than August 2, 2020; however, there was no update documented in the record at the time of the inspection.
Client #7 was admitted on May 14, 2020 and was still active at the time of the inspection. A comprehensive treatment plan was completed on June 10, 2020 and an update was due no later than August 10, 2020; however, there was no update documented in the 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
In this citation the TPR was not performed in the required 60 day time frame. The director reeducated the staff on the requirements for TRP's . The new Facilities director has implemented a new policy in which the Director will oversee all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit and continuing through to discharge of a client. This Policy was implemented on 3/15/2020. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete all admit and discharge file paperwork to comply with DDAP regulations. This policy is still in effect September 1 2020 |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) 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 on August 31, 2020, there was no documentation that the clients received counseling services according to their individual treatment plan in client record # ' s 1, 2, 5, 6 and 7.
Client #1 was admitted on June 10, 2020 and was still active at the time of the inspection. A counselor ' s case consultation note dated June 10, 2020 stated weekly individual counseling sessions. The record of service showed one individual counseling session on July 8, 2020. No documentation of other individual sessions was found in the client ' s record.
Client #2 was admitted on May 5, 2020 and was still active at the time of the inspection. The comprehensive treatment plan, dated May 18, 2020, indicated weekly individual sessions. The record of service and progress notes indicated that the client did not receive individual sessions between August 5 - August 17, 2020. No documentation of other individual sessions after August 18, 2020.
Client #5 was admitted on January 15, 2020 and discharged on July 14, 2020. A treatment plan update, dated May 21, 2020, stated weekly individual counseling sessions. According to the record of service, the client did not receive any individual sessions after May 28, 2020.
Client #6 was admitted on November 18, 2019 and discharged on July 28, 2020. Treatment plan updates dated April 3, 2020 and June 3, 2020 stated weekly individual counseling sessions. The record of service and progress notes indicated that the client did not receive individual sessions between May 21 - June 3, June 19- July 1 and July 3 - July 16, 2020.
Client #7 was admitted on May 14, 2020 and was still active at the time of the inspection. The comprehensive treatment plan dated June 10, 2020 stated weekly individual and group sessions. The record of service and progress notes indicated that the client did not receive individual sessions between May 15 - 31, July 2 - 22 and no sessions after July 27, 2020. In addition, the first documented group session was on July 7, 2020.
These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the September 5, 2019 annual licensing inspection and the March 11, 2019 provisional licensing inspection.
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Plan of Correction
It was revealed during the inspection on August 31 202 that there were multiple deficiencies in regards to documentation of client No shows and cancelations within the file records. Due to the mandated stay at home order due to the Covid 19 pandemic , there were multiple clients who disengaged from services . The facility attempted to reengage with those clients via phone and text but to no avail. When the clients reached their max date they were administratively discharged due to noncompliance . The facility failed to document all attempts to contact. The facilities director has instructed all staff on the requirement to document all interactions with clients. The facilities director will continue to audit and monitor all client interactions . This policy is in effect on September 1 2020 . |
709.93(a) 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:
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Observations
Based on a review of client records on August 31, 2020, the facility failed to provide a complete client record, which is to include progress notes, aftercare plans, discharge summaries, record of service and documentation of follow-up information, in client record # ' s 1, 2, 3, 4, 5, 6, and 7.
Client #1 was admitted on June 10, 2020 and was still active at the time of the inspection. The client record was missing a progress note from the July 8, 2020 individual counseling session.
Client #2 was admitted on May 5, 2020 and was still active at the time of the inspection. The client record did not include a record of service for August 2020.
Client #3 was admitted on May 18, 2020 and was still active at the time of the inspection. The client record did not include a record of service for August 2020.
Client #4 was admitted on June 1, 2020 and discharged on July 13, 2020. The client record did not include a record of service for July 2020, a discharge summary, an aftercare plan and follow-up documentation.
Client #5 was admitted on January 15, 2020 and was discharged on July 14, 2020. The client record did not include a discharge summary.
Client #6 was admitted on November 18, 2019 and discharged on July 28, 2020. The client record did not include a progress note for an individual session on July 28, 2020.
Client #7 was admitted on May 14, 2020 and was still active at the time of the inspection. The client record did not include progress notes for individual sessions on June 1, June 25, June 30, July 1, July 23 and 27, 2020. In addition, there were no progress notes for group sessions on July 7, July 14, and July 21, 2020. There was not a record of service for August 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The records of service were in another location at the time of the audit. The facilities director and the office manager will make sure that the records of service are maintained within the client files . The new Facilities director has implemented a new policy in which the Director will oversee all chart audits on a monthly basis. The Facilities director has also implemented a real time auditing procedure on all admit files to assure that all parts of the file are populated on Admit. This Policy was implemented on 3/15/2020. The facilities director will then inspect every file and hold the clinician accountable for not following this procedure. The facilities director will also retrain all staff and new hires on the proper way to complete all admit file paperwork to comply with DDAP regulations. This policy is in effect on September 1 2020. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical site inspection conducted on August 31, 2020, the facility failed to display their hours of operation visible to the general public.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of inspection the hours of operation had fallen off of the door . The facilities director and the office manager will assure that the Office hours are posted in multiple places daily . This policy is in effect September 1 2020. |