INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 15, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, 717 Health LLC dba Northeast Wellness Collective 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of personnel records, the facility failed to ensure that the clinical supervisor participated in documented monthly meetings with their supervisors to discuss duties and performance for the first 6 months of employment in that position.
Employee #3 was contracted as a clinical supervisor on May 13, 2024 and was still in that position at the time of the inspection. No supervision was documented.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Who will correct the deficiency (job title, not name)
Executive Director
2. How the deficiency will be corrected (staff meeting, training, etc.)
The Executive Director will meet with the Clinical Supervisor for the next 6 months and document our meetings.
3. When will they be corrected (corrective action date)
The Executive Director has met with Clinical Supervisor for the month of January 20 2025 and will continue to meet with her until June 2025
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
The Executive Director will document in clinical notes the regulation and make sure that moving forward, anyone put in the Clinical Supervisor role has 6 months of supervision.
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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 plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. There was a camera in the group counseling room.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Who will correct the deficiency (job title, not name)
Executive Director
2. How the deficiency will be corrected (staff meeting, training, etc.)
Removal of the camera
3. When will they be corrected (corrective action date)
1/20/2025
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
During monthly physical plant inspections, ensure clients have privacy during their counseling sessions.
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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
Based on a review of fire drill logs from May-December, 2024, the facility failed to document exit routes used during fire drills.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Who will correct the deficiency (job title, not name)
Executive Director
2. How the deficiency will be corrected (staff meeting, training, etc.)
Forms has been updated to document exit routes on the log
3. When will they be corrected (corrective action date)
1/20/2025
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
Executive Director will review document on a yearly basis to make sure it aligns with regulations |
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 a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in two out of six applicable records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #2 was admitted on July 16, 2024 and discharged on September 27, 2024.
Client #3 was admitted on November 4, 2024 and discharged on December 20, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Who will correct the deficiency (job title, not name)
Executive Director
2. How the deficiency will be corrected (staff meeting, training, etc.)
Staff meeting to review what documents need to be done at intake.
3. When will they be corrected (corrective action date)
A staff meeting will be conducted on 2/5/2025 to review the paperwork for the intake process.
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
The Executive Director will complete chart audits at intake and discharge
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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 a completed informed and voluntary consent which included the specific information to be disclosed in one out of six applicable records reviewed.
Client #4 was admitted on November 28, 2024 and was still active at the time of the inspection. A release of information form signed November 27, 2024 was to a family member.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Who will correct the deficiency (job title, not name)
Executive Director
2. How the deficiency will be corrected (staff meeting, training, etc.)
Staff meeting will be held to review the intake paperwork
3. When will they be corrected (corrective action date)
Staff meeting will be on 2/5/25
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
The Executive Director will conduct chart audits at intake and discharge.
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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 with the client within the guidelines established by the facility's policy and procedures manual in six out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within five days following admission.
Client #1 was admitted on July 10, 2024 and discharged on October 11, 2024. The comprehensive treatment plan was due no later than July 15, 2024; however, it was not completed until October 3, 2024.
Client #2 was admitted on July 16, 2024 and discharged on September 27, 2024. The comprehensive treatment plan was due no later than July 21, 2024; however, none was completed.
Client #3 was admitted on November 4, 2024 and discharged on December 20, 2024. The comprehensive treatment plan was due no later than November 9, 2024; however, it was not completed until November 27, 2024 and was not developed with the client.
Client #4 was admitted on November 28, 2024 and was still active at the time of the inspection. The comprehensive treatment plan completed on December 2, 2024 was not developed with the client.
Client #5 was admitted on January 7, 2025 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than January 12, 2025; however, it was not completed until January 14, 2025 and was not developed with the client.
Client #7 was admitted on October 14, 2024 and discharged on November 8, 2024. The comprehensive treatment plan was due no later than October 19, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Who will correct the deficiency (job title, not name)
Executive Director
2. How the deficiency will be corrected (staff meeting, training, etc.)
Executive Director will review time frames with staff at staff meeting on 2/5/25
3. When will they be corrected (corrective action date)
2/5/25 at staff meeting
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
The Executive Director will complete chart audits at intake and discharge
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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 document an aftercare 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 that an aftercare plan must be completed prior to discharge.
Client #1 was admitted on July 10, 2024 and discharged on October 11, 2024. No aftercare plan was documented.
Client #2 was admitted on July 16, 2024 and discharged on September 27, 2024. No aftercare plan was documented.
Client #7 was admitted on October 14, 2024 and discharged on November 8, 2024. No aftercare plan was documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name)
Executive Director
2. How the deficiency will be corrected (staff meeting, training, etc.)
Staff meeting on 2/5/25 will review documentation requirements for clients charts
3. When will they be corrected (corrective action date)
2/5/2025 staff meeting
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
The Executive Director will complete chart audits at intake and discharge
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary within guidelines established by the facility's policy and procedures manual in two out of five applicable records reviewed. The facility's policy and procedures manual states the that discharge summary must be completed 7 days following discharge.
Client #1 was admitted on July 10, 2024 and discharged on October 11, 2024. No discharge summary was documented.
Client #2 was admitted on July 16, 2024 and discharged on September 27, 2024. No discharge summary was documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name)
Executive Director
2. How the deficiency will be corrected (staff meeting, training, etc.)
Review documentation requirements with staff at staff meeting 2/5/25
3. When will they be corrected (corrective action date)
2/5/2025
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
The Executive Director will complete chart audits at intake and discharge |
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 document follow up information within guidelines established by the facility's policy and procedures manual in five out of five applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed 7, 30, 60, 90 days, 6 month and 1 year following discharge. No follow ups were completed.
Client #1 was admitted on July 10, 2024 and discharged on October 11, 2024.
Client #2 was admitted on July 16, 2024 and discharged on September 27, 2024.
Client #3 was admitted on November 4, 2024 and discharged on December 20, 2024.
Client #6 was admitted on December 12, 2024 and discharged on December 20, 2024.
Client #7 was admitted on October 14, 2024 and discharged on November 8, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name)
Executive Director
2. How the deficiency will be corrected (staff meeting, training, etc.)
Review at the staff meeting the documentation requirements
3. When will they be corrected (corrective action date)
2/5/2025
4. How will the facility ensure the
deficiency does not recur (periodic training, chart reviews, etc)
The Executive Director will complete chart audits at intake and discharge |