INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigation conducted on May 18, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Beyond Addiction Recovery and Treatment Center 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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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel files, the facility failed to instruct all staff in the use of fire extinguishers upon employment in five out of five files reviewed. All staff received fire extinguisher training on March 27, 2023.Employee #1 was hired as project director on April 14, 2022 and was still in that position at the time of the inspection. Employee #2 was hired as clinical supervisor on April 14, 2022 and was still in that position at the time of the inspection.Employee #3 was hired as a counselor on December 26, 2022 and was still in that position at the time of the inspection.Employee #4 was hired as a counselor on January 16, 2023 and was still in that position at the time of the inspection.Employee #5 was hired as a counselor on February 21, 2023 and was still in that position at the time of the inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director has updated the hiring policy for all new hires to be provided with proper fire extinguisher training within 5 days of their hire. This change was completed in the new hire paperwork as of 6/16/2023.
Executive Director will complete all fire extinguisher training and file certificate of completion in the employee's file. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 December 2022 - April 2023 fire drills logs, the facility failed to include whether the fire alarm was operational on all logs reviewed. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director reviewed the fire drill log template.
Executive Director changed the fire drill log template to reflect needed changes - checking if the fire alarm was operational at the time of the fire drill. This change to the fire drill log was completed on 6/16/2023.
Executive Director and Clinical Director will oversee and sign off on all fire drills to ensure proper documentation is on the fire drill log. Two signatures will be on all fire drills to ensure proper documentation moving forward. |
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 the review of the facility's policy and procedures manual, the facility failed to have written procedures for the management of treatment services includes timeline for completion of comprehensive treatment plans. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director updated the policies and procedures manual to outline and dictate the written procedures for the management of treatment services includes timeline for completion of comprehensive treatment plans. This was completed by the Clinical Director on 6/16/2023. Executive Director reviewed the policy and signed off on the appropriate changes. |
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, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one out of seven records reviewed.Client #1 was admitted on April 12, 2023 and was still active at the time of the inspection. There was no release form to the funding source in the client's record. Staff confirmed billing had occurred. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director reviewed deficiency and targeted training to have all staff compete upon hiring and annually. Executive Director added training
All staff completed HIPAA training and a DDAP Client Confidentiality training to ensure the due diligence and understanding of client consents and releases prior to actions with information occurring. These trainings were completed from 6/12/2032-6/16/2023.
Executive and Clinical Directors also ran a staff meeting/training to explain the issues found during the inspection and allowed for questions to be asked by staff. This was completed on 6/15/2023.
All staff moving forwards will complete DDAP confidentiality training within 30 days of employment.
Executive and Clinical Directors will use our 30 days reviews to document if trainings were completed and monthly staff meetings ran by Executive and Clinical Directors will include continual review of issues.
Clinical Director will also continually do chart audits to ensure consents are signed and documented properly on a weekly basis. |
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 one out of seven records reviewed, as the form was missing purpose of disclosure.Client #1 was admitted on April 12, 2023 and was still active at the time of the inspection. The consent form was dated April 16, 2023 to a community organization.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director reviewed deficiency and targeted training to have all staff compete upon hiring and annually. Executive Director added training
All staff completed HIPAA training and a DDAP Client Confidentiality training to ensure the due diligence and understanding of client consents and releases prior to actions with information occurring. These trainings were completed from 6/12/2032-6/16/2023.
Executive and Clinical Directors also ran a staff meeting/training to explain the issues found during the inspection and allowed for questions to be asked by staff. This was completed on 6/15/2023.
All staff moving forwards will complete DDAP confidentiality training within 30 days of employment.
Executive and Clinical Directors will use our 30 days reviews to document if trainings were completed and monthly staff meetings ran by Executive and Clinical Directors will include continual review of issues.
Clinical Director will also continually do chart audits to ensure consents are signed and documented properly on a weekly basis. |
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, the facility failed to document a completed consent to release information form in seven out of seven records reviewed, as all the forms did not include that a copy of the consent was offered to the client. Client #1 was admitted on April 14, 2023 and was still active at the time of the inspection. Seven signed consents were in the client's record.Client #2 was admitted on April 17, 2023 and was still active at the time of the inspection. Seven signed consents were in the client's record.Client #3 was admitted on April 24, 2023 and was still active at the time of the inspection. Twelve signed consents were in the client's record.Client #4 was admitted on March 30, 2023 and discharged on April 10, 2023. Eleven signed consents were in the client's record.Client #5 was admitted on February 3, 2023 and discharged on March 24, 2023. Client was readmitted on April 5, 2023 and was still active at the time of the inspection. Eighteen signed consents were in the client's record. Client #6 was admitted on March 1, 2023 and discharged on April 20, 2023. Eighteen signed consents were in the client's record. Client #7 was admitted on January 9, 2023 and discharged on January 30, 2023. Twenty-one consents were in the client's record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical Director worked with our Electronic Records System company to ensure all consent forms had the function to offer a copy of the consent to the client. All clients can now deny or accept a copy of all consent forms they signed at any time. This was completed by the Clinical Director on 6/13/2023
Executive Director reviewed deficiency and targeted training to have all staff compete upon hiring and annually. Executive Director added training
All staff completed HIPAA training and a DDAP Client Confidentiality training to ensure the due diligence and understanding of client consents and releases prior to actions with information occurring. These trainings were completed from 6/12/2032-6/16/2023.
Executive and Clinical Directors also ran a staff meeting/training to explain the issues found during the inspection and allowed for questions to be asked by staff. This was completed on 6/15/2023.
All staff moving forwards will complete DDAP confidentiality training within 30 days of employment.
Executive and Clinical Directors will use our 30 days reviews to document if trainings were completed and monthly staff meetings ran by Executive and Clinical Directors will include continual review of issues.
Clinical Director will also continually do chart audits to ensure consents are signed and documented properly on a weekly basis. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to ensure that the clients were made aware of all of their rights including they shall retain civil rights and liberties in seven out of seven records reviewed.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director made the required changes to the documentation with the help of KIPU, the electronic health record system that Beyond Addiction utilizes. This change was confirmed by the Executive Director on 6/19/2023.
The clinical Director went over this documentation change with all of the clinical team during their morning meeting on 6/19/2023 so they can educate patients/clients if they have questions. |
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 client records, the facility failed to ensure that the clients were made aware of all of their rights including they may not be discriminated against based on marital status in seven out of seven records reviewed.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director made the required changes to the documentation with the help of KIPU, the electronic health record system that Beyond Addiction utilizes. This change was confirmed by the Executive Director on 6/19/2023.
The clinical Director went over this documentation change with all of the clinical team during their morning meeting on 6/19/2023 so they can educate patients/clients if they have questions. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to ensure that the clients were made aware of all of their rights including having the right to appeal a decision limiting access to their records in seven out of seven records reviewed.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director made the required changes to the documentation with the help of KIPU, the electronic health record system that Beyond Addiction utilizes. This change was confirmed by the Executive Director on 6/19/2023.
The clinical Director went over this documentation change with all of the clinical team during their morning meeting on 6/19/2023 so they can educate patients/clients if they have questions. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to ensure that the clients were made aware of all of their rights including having the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in seven out of seven records reviewed.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director made the required changes to the documentation with the help of KIPU, the electronic health record system that Beyond Addiction utilizes. This change was confirmed by the Executive Director on 6/19/2023.
The clinical Director went over this documentation change with all of the clinical team during their morning meeting on 6/19/2023 so they can educate patients/clients if they have questions. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to ensure that the clients were made aware of all of their rights including having the right to submit rebuttal data or memoranda to their own records in seven out of seven records reviewed.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director made the required changes to the documentation with the help of KIPU, the electronic health record system that Beyond Addiction utilizes. This change was confirmed by the Executive Director on 6/19/2023.
The clinical Director went over this documentation change with all of the clinical team during their morning meeting on 6/19/2023 so they can educate patients/clients if they have questions. |
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, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client in one out of one applicable record reviewed.Client #4 was admitted on March 30, 2023 and discharged on April 10, 2023. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director reviewed the deficiency and implemented the following plan:
The clinical and Executive Director drafted a letter for clients to receive while departing the facility (or to be sent if they do not take the letter) for an involuntary termination from treatment. This letter is to be given to the client from the counselor or covering counseling staff member. If it is not given directly, it will be sent in the mail to their current address on the following day of business.
The clinical Director met with all clinical staff to educate them on the necessity of completing these letters and documenting them in the charts that they received a letter acknowledging their involuntary termination from treatment. This meeting was held on 6/14/2023.
Executive Director oversaw that the termination letter was implemented.
It is now a requirement to have in the chart before it is considered closed.
The clinical director will review this during chart audits to ensure this is being done. |