INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 25, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Council of Southeast Pennsylvania, 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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709.30 (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 include documentation verifying the written acknowledgement by clients that they had been informed of their right to retain civil rights and liberties except as provided by statute and no client may be deprived of a civil right solely by reason of treatment in twelve of fifteen client records reviewed.
Client #1 was admitted to the outpatient activity on November 21, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #2 was admitted to the outpatient activity on August 6, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #3 was admitted to the outpatient activity on January 15, 2025 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #4 was admitted to the outpatient activity on January 23, 2025 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #5 was admitted to the outpatient activity on June 26, 2024 and was discharged on August 20, 2024. There was no written acknowledgement for this client right documented in the record.
Client #6 was admitted to the outpatient activity on August 7, 2024 and was discharged on October 2, 2024. There was no written acknowledgement for this client right documented in the record.
Client #7 was admitted to the outpatient activity on September 18, 2024 and was discharged on November 12, 2024. There was no written acknowledgement for this client right documented in the record.
Client #9 was admitted to the intake, evaluation and referral activity on August 1, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #10 was admitted to the intake, evaluation and referral activity on September 16, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #11 was admitted to the intake, evaluation and referral activity on July 2, 2024 and was discharged on October 7, 2024. There was no written acknowledgement for this client right documented in the record.
Client #12 was admitted to the intake, evaluation and referral activity on August 26, 2024 and was discharged on November 12, 2024. There was no written acknowledgement for this client right documented in the record.
Client #15 was admitted to the intake, evaluation and referral activity on April 18, 2024. There was no written acknowledgement for this client right documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency was further evaluated by the Director of Intervention Services. It was determined that the issue was related to the Consent to Treatment was missing from an Intake Packet in our Docusign system. This was corrected on 2/27/2025. In addition, the following changes will be completed and implemented by the Director of Intervention Services by 3/18/25:
1. The Client Rights document and the Consent to Treatment have been combined into a single document to ensure that both are imported to the client chart.
2. The new document will replace the prior documents in our EHR, Electronic Intake Packets, and hardcopies of Intake Packets.
3. Assessors and Counselors will be responsible for ensuring that the Client Rights and Consent to Treatment form will is reviewed with the client at the time of assessment and upon admission into treatment at the Council if applicable.
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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 include documentation verifying the written acknowledgement by clients that 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 in twelve of fifteen client records reviewed.
Client #1 was admitted to the outpatient activity on November 21, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #2 was admitted to the outpatient activity on August 6, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #3 was admitted to the outpatient activity on January 15, 2025 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #4 was admitted to the outpatient activity on January 23, 2025 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #5 was admitted to the outpatient activity on June 26, 2024 and was discharged on August 20, 2024. There was no written acknowledgement for this client right documented in the record.
Client #6 was admitted to the outpatient activity on August 7, 2024 and was discharged on October 2, 2024. There was no written acknowledgement for this client right documented in the record.
Client #7 was admitted to the outpatient activity on September 18, 2024 and was discharged on November 12, 2024. There was no written acknowledgement for this client right documented in the record.
Client #9 was admitted to the intake, evaluation and referral activity on August 1, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #10 was admitted to the intake, evaluation and referral activity on September 16, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #11 was admitted to the intake, evaluation and referral activity on July 2, 2024 and was discharged on October 7, 2024. There was no written acknowledgement for this client right documented in the record.
Client #12 was admitted to the intake, evaluation and referral activity on August 26, 2024 and was discharged on November 12, 2024. There was no written acknowledgement for this client right documented in the record.
Client #15 was admitted to the intake, evaluation and referral activity on April 18, 2024. There was no written acknowledgement for this client right documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency was further evaluated by the Director of Intervention Services. It was determined that the issue was related to the Consent to Treatment was missing from an Intake Packet in our Docusign system. This was corrected on 2/27/2025. In addition, the following changes will be completed and implemented by the Director of Intervention Services by 3/18/25:
1. The Client Rights document and the Consent to Treatment have been combined into a single document to ensure that both are imported to the client chart.
2. The new document will replace the prior documents in our EHR, Electronic Intake Packets, and hardcopies of Intake Packets.
3. Assessors and Counselors will be responsible for ensuring that the Client Rights and Consent to Treatment form will is reviewed with the client at the time of assessment and upon admission into treatment at the Council if applicable.
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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 include documentation verifying the written acknowledgement by that they had been informed of their right to appeal a decision limiting access to their records to the director in twelve of fifteen client records reviewed.
Client #1 was admitted to the outpatient activity on November 21, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #2 was admitted to the outpatient activity on August 6, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #3 was admitted to the outpatient activity on January 15, 2025 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #4 was admitted to the outpatient activity on January 23, 2025 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #5 was admitted to the outpatient activity on June 26, 2024 and was discharged on August 20, 2024. There was no written acknowledgement for this client right documented in the record.
Client #6 was admitted to the outpatient activity on August 7, 2024 and was discharged on October 2, 2024. There was no written acknowledgement for this client right documented in the record.
Client #7 was admitted to the outpatient activity on September 18, 2024 and was discharged on November 12, 2024. There was no written acknowledgement for this client right documented in the record.
Client #9 was admitted to the intake, evaluation and referral activity on August 1, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #10 was admitted to the intake, evaluation and referral activity on September 16, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #11 was admitted to the intake, evaluation and referral activity on July 2, 2024 and was discharged on October 7, 2024. There was no written acknowledgement for this client right documented in the record.
Client #12 was admitted to the intake, evaluation and referral activity on August 26, 2024 and was discharged on November 12, 2024. There was no written acknowledgement for this client right documented in the record.
Client #15 was admitted to the intake, evaluation and referral activity on April 18, 2024. There was no written acknowledgement for this client right documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency was further evaluated by the Director of Intervention Services. It was determined that the issue was related to the Consent to Treatment was missing from an Intake Packet in our Docusign system. This was corrected on 2/27/2025. In addition, the following changes will be completed and implemented by the Director of Intervention Services by 3/18/25:
1. The Client Rights document and the Consent to Treatment have been combined into a single document to ensure that both are imported to the client chart.
2. The new document will replace the prior documents in our EHR, Electronic Intake Packets, and hardcopies of Intake Packets.
3. Assessors and Counselors will be responsible for ensuring that the Client Rights and Consent to Treatment form will is reviewed with the client at the time of assessment and upon admission into treatment at the Council if applicable.
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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 include documentation verifying the written acknowledgement that they had been informed of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records in twelve of fifteen client records reviewed.
Client #1 was admitted to the outpatient activity on November 21, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #2 was admitted to the outpatient activity on August 6, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #3 was admitted to the outpatient activity on January 15, 2025 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #4 was admitted to the outpatient activity on January 23, 2025 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #5 was admitted to the outpatient activity on June 26, 2024 and was discharged on August 20, 2024. There was no written acknowledgement for this client right documented in the record.
Client #6 was admitted to the outpatient activity on August 7, 2024 and was discharged on October 2, 2024. There was no written acknowledgement for this client right documented in the record.
Client #7 was admitted to the outpatient activity on September 18, 2024 and was discharged on November 12, 2024. There was no written acknowledgement for this client right documented in the record.
Client #9 was admitted to the intake, evaluation and referral activity on August 1, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #10 was admitted to the intake, evaluation and referral activity on September 16, 2024 and was active at the time of the inspection. There was no written acknowledgement for this client right documented in the record.
Client #11 was admitted to the intake, evaluation and referral activity on July 2, 2024 and was discharged on October 7, 2024. There was no written acknowledgement for this client right documented in the record.
Client #12 was admitted to the intake, evaluation and referral activity on August 26, 2024 and was discharged on November 12, 2024. There was no written acknowledgement for this client right documented in the record.
Client #15 was admitted to the intake, evaluation and referral activity on April 18, 2024. There was no written acknowledgement for this client right documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency was further evaluated by the Director of Intervention Services. It was determined that the issue was related to the Consent to Treatment was missing from an Intake Packet in our Docusign system. This was corrected on 2/27/2025. In addition, the following changes will be completed and implemented by the Director of Intervention Services by 3/18/25:
1. The Client Rights document and the Consent to Treatment have been combined into a single document to ensure that both are imported to the client chart.
2. The new document will replace the prior documents in our EHR, Electronic Intake Packets, and hardcopies of Intake Packets.
3. Assessors and Counselors will be responsible for ensuring that the Client Rights and Consent to Treatment form will is reviewed with the client at the time of assessment and upon admission into treatment at the Council if applicable.
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709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review and a discussion with facility staff, the facility failed to maintain a recordkeeping system that allows for the identification of clients' admissions and discharges within a specific time period.
The facility was not discharging clients from the intake, evaluation and referral activity, upon a referral to DUI education or Highway Safety School, which are other programs within the facility's organization. Therefore, the outpatient activity client admission dates were the dates the clients were assessed during the intake, evaluation and referral activity, which was approximately one to six months prior to receiving outpatient treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To address this deficiency, updates to the Referral and Admission to Treatment procedure will be made and the Director of Intervention Services will review the policy and procedure in group and individual supervision with Assessors and Counselors by 3/18/2025. The information to be reviewed is as follows:
1. Clients must be referred and admitted to the appropriate level of
care available within 14 days of the LOCA. Priority Populations must be admitted to the appropriate level of care immediately. Individuals in need of withdrawal management must be admitted to treatment within 24 hours. If these time frames cannot be met, the assessor must document the reason in the individual's file.
2. An individual is admitted to treatment at the first attended appointment with a provider after the LOCA has been completed. A treatment episode is a combined service provided to an individual during a period of treatment and begins with the admission to treatment. The substance misuse treatment episode should be assumed to have ended if the individual has not
received a treatment service
30 days.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to ensure intake procedures included the documentation of a consent to treatment in seven of eight applicable client records reviewed.
Client #1 was admitted to the outpatient activity on November 21, 2024 and was active at the time of the inspection. There was no consent to treatment form documented in the record at the time of the inspection.
Client #2 was admitted to the outpatient activity on August 6, 2024 and was active at the time of the inspection. There was no consent to treatment form documented in the record at the time of the inspection.
Client #3 was admitted to the outpatient activity on January 15, 2025 and was active at the time of the inspection. There was no consent to treatment form documented in the record at the time of the inspection.
Client #4 was admitted to the outpatient activity on January 23, 2025 and was active at the time of the inspection. There was no consent to treatment form documented in the record at the time of the inspection.
Client #5 was admitted to the outpatient activity on June 26, 2024 and was discharged on August 20, 2024. There was no consent to treatment form documented in the record at the time of the inspection.
Client #6 was admitted to the outpatient activity on August 7, 2024 and was discharged on October 2, 2024. There was no consent to treatment form documented in the record at the time of the inspection.
Client #7 was admitted to the outpatient activity on September 18, 2024 and was discharged on November 12, 2024. There was no consent to treatment form 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
This deficiency was further evaluated by the Director of Intervention Services. It was determined that the issue was related to the Consent to Treatment was missing from an Intake Packet in our Docusign system. This was corrected on 2/27/2025. In addition, the following changes will be completed and implemented by the Director of Intervention Services by 3/18/25:
1. The Client Rights document and the Consent to Treatment have been combined into a single document to ensure that both are imported to the client chart.
2. The new document will replace the prior documents in our EHR, Electronic Intake Packets, and hardcopies of Intake Packets.
3. Assessors and Counselors will be responsible for ensuring that the Client Rights and Consent to Treatment form will is reviewed with the client at the time of assessment and upon admission into treatment at the Council if applicable. |
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 review and update treatment and rehabilitation plans at least every sixty days in two of three applicable client records reviewed.
Client #1 was admitted to the outpatient activity on November 21, 2024 and was active at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on December 13, 2024. The first update was due no later than February 13, 2025; however, the update was not completed as of the date of the inspection.
Client #2 was admitted to the outpatient activity on August 6, 2024 and was active at the time of the inspection. A treatment plan update was completed on December 11, 2024. The next update was due no later than February 9, 2025; however, the update was completed on February 19, 2025.
This is a repeat citation from the February 7, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Plan Update Procedure:
The Director of Intervention Services will implement the additions to the Treatment Plan Update Procedure by 3/18/2025. These updates will be reviewed with the Outpatient Counselor by 3/18/2025.
The assigned Counselor will be responsible for the following:
If the client does not participate in updating their treatment plan by the 60-day deadline, the counselor will complete a treatment plan update indicating the client's non-participation. Progress will be documented using objective data only, without client input. A treatment plan update will be conducted with the client at the next available session. This update will ensure that the treatment plan remains:
Person-centered
Action-oriented
Strength-based
A collaborative working document between the provider and the client.
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709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
Based on a review of client records, the facility failed to ensure a consent to treatment form was completed and signed by the client and intake worker at intake in in five of seven applicable client records reviewed.
Client #9 was admitted to the intake, evaluation and referral activity on August 1, 2024 and was active at the time of the inspection. There was no consent to treatment form documented in the record at the time of the inspection.
Client #10 was admitted to the intake, evaluation and referral activity on September 16, 2024 and was active at the time of the inspection. There was no consent to treatment form documented in the record at the time of the inspection.
Client #11 was admitted to the intake, evaluation and referral activity on July 2, 2024 and was discharged on October 7, 2024. There was no consent to treatment form documented in the record at the time of the inspection.
Client #12 was admitted to the intake, evaluation and referral activity on August 26, 2024 and was discharged on November 12, 2024. There was no consent to treatment form documented in the record at the time of the inspection.
Client #15 was admitted to the intake, evaluation and referral activity on April 18, 2024. There was no consent to treatment form 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
This deficiency was further evaluated by the Director of Intervention Services. It was determined that the issue was related to the Consent to Treatment was missing from an Intake Packet in our Docusign system. This was corrected on 2/27/2025. In addition, the following changes will be completed and implemented by the Director of Intervention Services by 3/18/25:
1. The Client Rights document and the Consent to Treatment have been combined into a single document to ensure that both are imported to the client chart.
2. The new document will replace the prior documents in our EHR, Electronic Intake Packets, and hardcopies of Intake Packets.
3. Assessors and Counselors will be responsible for ensuring that the Client Rights and Consent to Treatment form will is reviewed with the client at the time of assessment and upon admission into treatment at the Council if applicable.
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