INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 18, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Perry Human Services, Inc.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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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 a review of client records, the facility failed to 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 specific information disclosed. This was observed in one out of seven records reviewed.
Client #1 was admitted on November 14, 2024, and was still active at the time of the inspection. A release of information form, for probation, was signed and dated on November 14, 2024; however, it did not document the information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/18/2025, I will discuss discrepancies with the counselor and explain proper documentation of releases. Then, by 2/28/2025, I will have the counselor complete a new release with the proper items checked off.
Beginning 2/28/2025, an audit tracking sheet will be implemented to track completed documentation. Depending on its severity, the sheet will be reviewed weekly or monthly. |
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 a review of client records, the facility failed to 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 purpose of disclosure. This was observed in one out of seven records reviewed.
Client #1 was admitted on November 14, 2024, and was still active at the time of the inspection. A release of information form, for probation, was signed and dated on November 14, 2024; however, it did not document the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
I will discuss this with the counselor on 2/27/25 and have them meet with the client by 3/14/25 to sign a new consent form.
Beginning 2/28/2025, an audit tracking sheet will be implemented to track completed documentation. Depending on its severity, the sheet will be reviewed weekly or monthly. |
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 of a client consent shall be offered to the client and a copy maintained in the client record in three out of seven client records reviewed.
Client #1 was admitted on November 14, 2024, and was still active at the time of the inspection. A release of information was completed on November 14, 2024, for probation, it did not contain documentation that a copy had been offered to the client.
Client #2 was admitted on July 10, 2024, and was still active at the time of the inspection. A release of information was completed on July 10, 2024, for the Single County Authority (SCA), it did not contain documentation that a copy had been offered to the client.
Client #7 was admitted on July 12, 2024, and was discharged on December 27, 2024. A release of information form, for probation was signed and dated on July 12, 2024, it did not contain documentation that a copy had been offered to the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The director will create a workflow checklist to audit client charts and implement it on 2/25/25. This comprehensive checklist will include a description of the status of incomplete or missing documentation.
Additionally, Clients #1 and #2 will be offered a copy of said consent by April 1, 2025. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of five applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed between within thirty days following admission.
Client #1 was admitted on November 14, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 14, 2024; however, there was no documentation of it being completed at the time of the inspection.
Client #3 was admitted on December 18, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than January 18, 2025; however, there was no documentation of it being completed at the time of the inspection.
Client #7 was admitted on July 12, 2024, and discharged on December 27, 2024. A comprehensive treatment plan was due no later than August 12, 2024; however, it was not completed until December 13, 2024.
This is a repeat citation from the December 20, 2023, licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The director will create a workflow checklist to audit client charts and implement it on 2/25/25. This comprehensive checklist will describe the status of incomplete or missing documentation and due dates.
The director will have the counselor complete a comprehensive treatment plan for client #1 on 3/26/25. The comprehensive treatment plan will be completed on 4/4/25 for client #3. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of two applicable records reviewed.
Client #2 was admitted on July 10, 2024, and was still active at the time of the inspection. A treatment plan update was completed on November 25, 2024, and the next update was due no later than January 25, 2025; however, there was no documentation of an updated treatment plan at the time of the inspection.
Client #5 was admitted on May 30, 2024, and discharged on January 15, 2025. A treatment plan was completed on August 20, 2024, and the next update was due no later than October 20, 2024; however, there was no documentation of an updated treatment plan at the time of the inspection.
This is a repeat citation from the December 20, 2023, licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The director will create a workflow checklist to audit client charts and implement it on 2/25/25. This comprehensive checklist will describe the status of incomplete or missing documentation and due dates.
An updated treatment was completed on 3/4/2025. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, in one out three applicable records reviewed, which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following: aftercare plan,
Client #5 was admitted on May 30, 2024, and was discharged on January 15, 2025. .
This is a repeat citation from the December 20, 2023, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The director will create a workflow checklist to audit client charts and implement it on 2/25/25. This comprehensive checklist will describe the status of incomplete or missing documentation. Additionally, staff were trained on this issue on 2/28/2025 during our weekly treatment meeting. Consequently, staff were informed that this would be reviewed weekly until everyone was on the same page. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, in four out of four applicable records reviewed, 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: follow-up information. The facility policy is to follow-up with all discharged clients within seven days of discharge.
Client #4 was admitted on May 9, 2024, and was discharged on September 23, 2024. The client record did not contain documentation of a follow-up contact.
Client #5 was admitted on May 30, 2024 and was discharged on January 15, 2025. The client record did not contain documentation of a follow-up contact.
Client #6 was admitted on October 14, 2024, and was discharged on January 13, 2025. The client record did not contain documentation of a follow-up contact.
Client #7 was admitted on July 12, 2024, and was discharged on December 27, 2024. The client record did not contain documentation of a follow-up contact.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The director will create a workflow checklist to audit client charts and implement it on 2/25/25. This comprehensive checklist will describe the status of incomplete or missing documentation. Additionally, on 2/28/2025, during our weekly treatment meeting, staff were trained on this issue. Consequently, staff were informed that this would be reviewed weekly until everyone was on the same page. |