INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the Project and Facility Director during the facility's January 2021 through December 2021 training year.
Employee #2 was hired as the Facility Director on September 7, 2020. The personnel record documented 0 hours of training received during the reviewed training year.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Facility Director failed to ensure that all training certificates and feedback forms were provided to Human Resources for the annual training requirements. The Facility Director is scheduled to attend trainings in 2022 to ensure compliance with training requirements. Clinical Coordinator will develop and implement training tracker that includes the Project Director and Facility Director to monitor completion of traininigs within required timeframes, including tracking annual trainings for the Project Director and Facility Director. The Project Director and Facility Director will be responsible for notifying the Clinical Coordinator when they have completed a training and will send a copy of the certificate to Human Resources. Clinical Manager will monitor monthly to ensure compliance with annual trainings. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that all counselors completed 25 clock hours of annual training during the facility's January 2021 through December 2021 training year.
Employee #9 was hired as a counselor on November 11, 2009. The record documented 21.5 hours of training received during the reviewed training year.
Employee #14 was hired as a counselor on October 2, 2019. The record documented 12.75 hours of training received during the reviewed training year.
Employee #15 was hired as a counselor on May 21, 2015. The record documented 8.75 hours of training received during the reviewed training year.
This is a repeat citation from the May 18, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The two employees who did not complete the required number of annual trainings are part-time counselors with other full-time committments and had difficulty registering for trainings within their availability due to less trainings being offered since COVID-19. Clinical Coordinator will develop and implement training tracker to monitor completion of traininigs within required timeframes. In addition, the Clinical Coordinator will meet with all new hires to review and complete initial training plans that include timeframes for required trainings for both full-time and part-time staff. Expectations for initial trainings and annual trainings will be made clear. The Clinical Coordinator will also ensure that staff are made aware of internal trainings such as Holcomb Behavioral Health System's annual conference, utilization of the agency's internal Learning Management System (LMS), and specific D&A program trainings. The Clinical Coordinator will provide staff with information regarding external training opportunities, to include trainings offered through Chester County Drug and Alcohol and DDAP. The Clinical Coordinator will also be responsible for collecting trainings certificates and feedback forms upon completion of trainings, and provide copies to Human Resources.
Clinical Supervisor will review training trackers with staff during individual supervisions to ensure that staff members have identifed and are signed up for the earliest, open trainings for completion within mandated timeframes. The Clinical Coordinator will review trainings expectations of available upcoming trainings during weekly team meetings.
Clinical Manager will review training trackers with Clinical Coordinator one time monthly to ensure compliance with regulations surrounding necessary trainings completed within the reuired timeframes. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report, the facility failed to ensure that the Full Time Equivalent (FTE) counselor's outpatient caseload did not exceed 35 active clients in two of twelve counselors reviewed.
The counselor FTE is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee #7 was hired as a counselor on October 25, 2012 and was still employed at the time of the inspection. The counselor's caseload calculation was as follows: 30/40= .75(FTE); 30/.75= 40 which equals a client/counselor ratio of 40:1.
Employee #16 was hired as a counselor on November 29, 2021 and was still employed at the time of the inspection. The counselor's caseload calculation was as follows: 8/40= .2(FTE); 8/.2= 40 which equals a client/counselor ratio of 40:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The number of hours per week were not inputed correctly on the staffing requirements facility summary report, which caused the ratios to not calculate correctly. There is additional administrative time allotted for employee #7 and #16. Employee #7 has an additional 10 hours of administrative time, therefore, the ratio calculation is 40/40 = 1 FTE; 30/1 = 30, which equals a client/counselor ratio of 30:1. Employee #16 has an additional 2 hours of administrative time, therefore, the ration calculation is 10/40 = .25 FTE; 8/.25 = 32, which equals a client/counselor ratio of 32:1. To ensure compliance with requirements for client/counselor ratio, the Clinical Coordinator will maintain a tracking spreadsheet of caseloads for each counselor and will track the ratio of clients to ensure that the ratios fall within regulations and do not exceed 35 active clients. For any staff out of ratio, additional administrative time will be provided or caseload will be decreased. Clinical Manager will review monthly the caseload tracking sheet to ensure compliance. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's May 2021 through April fire drill log, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
The facility's hours of operation are Monday and Thursday 9:00AM - 9:00PM and Friday 9:00AM - 5:00PM. All the fire drills conducted, during the reviewed period, were completed at or prior to 4:00PM. None of the fire drills were conducted during the evening hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility did not monitor if fire drills were being completed on different days of the week, at different times of the day, and on different staffing shifts. To ensure compliance with fire safety, the EOC representative running the fire drills will be responsible for ensuring drills are ran on different days of the week, different times, and on different staffing shifts throughout the year. The Facility Director/Regional Director will work with the EOC representatives to ensure compliance and will review the dire drills monthly. The monthly report for fire drills will then be reviewed in the Facility's quality management meeting for compliance. The Project Director and Quality Management Committee will review monthly as additional oversight. |
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 review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in five of seven client records reviewed.
The facility policy and procedure manual stated that the initial treatment plan will be completed on the day of admission. Additionally, the facility policy and procedure manual stated that master treatment plan will be completed within 30 days of admission.
Client #3 was admitted on June 22, 2021 and was discharged on November 1, 2021. The initial treatment plan was due no later than June 22, 2021; however, it was completed on July 7, 2021. Additionally, the master treatment plan was due no later than July 22, 2021; however, it was completed on August 3, 2021.
Client #4 was admitted on September 20, 2021 and was discharged on December 23, 2021. The initial treatment plan was due no later than September 20, 2021; however, it was completed on October 8, 2021. Additionally, the master treatment plan was due no later than October 20, 2021; however, it was completed on November 4, 2021.
Client #5 was admitted on September 16, 2021 and was discharged on January 11, 2022. The initial treatment plan was due no later than September 16, 2021; however, it was completed on September 21, 2021. Additionally, the master treatment plan was due no later than October 16, 2021; however, it was completed on October 22, 2021.
Client #6 was admitted on September 22, 2021 and was active at the time of inspection. The initial treatment plan was due no later than September 22, 2021; however, it was completed on September 24, 2021. Additionally, the master treatment plan was due no later than October 22, 2021; however, it was completed on October 28, 2021.
Client #7 was admitted on November 23, 2021 and was active at the time of inspection. The initial treatment plan was due no later than November 23, 2021; however, it was completed on December 7, 2021. Additionally, the master treatment plan was due no later than December 23, 2021; however, it was completed on December 30, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The agency policy is to complete an initial treatment plan at day of admission. Admission is defined by the day a client is evaluated for treatment and enrolled into the program. During this inspection, the date of intake (i.e., the day a client is screened and scheduled at a later time for first appointment) was used as the admission date to calculate the timeliness of treatment plans. We believe this error was caused because the standard operating manual for substance use services did not include the definition for admission that is defined in the agency policies and procedures. The facility will ensure that the standard operating manual for substance use services reflects the same language as the agency policies and procedures, which states in Chapter 15.2.3 "The intake process does not reflect the client's admission to the agency for services/treatment as this occurs at the time of the first face-to-face clinical interaction, typically the clinical assessment. Treatment begins at the time of official admission." When using the first face-to-face clinical assessment date, as written in the agency's polices, Clients #3, #4, #5, #6, and #7 had treatment plans completed within the requirements timeframe. Therefore, the initial treatment plans and master treatment plans were in compliance if they were counted from the date of the first face to face clinical interaction as opposed to the intake date/phone screen. In addition, the Clinical Coordinator will maintain a tracking mechanism to monitor and ensure complaince with timeliness for initial and master treatment plans. The Clinical Coordinator will track weekly initial and master treatment that are needed. Treatment plan due dates for each client on their caseload will be emailed to all clinical staff on a weekly basis. Clinical staff will be asked to make an effort to complete treatment plan updates up to 10 days prior to treatment plan lapse in order to decrease the likelihood of treatment plan lapse. The Clinical Manager will review monthly for compliance |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in six of seven client records reviewed.
Client #1 was admitted on August 17, 2021 and was discharged on October 22, 2021. There were release of information forms to a physician, a funding source, a case management program, a probation and parole agency, and an emergency contact that were all signed and dated by the witness on August 23, 2021; however, the dated signature of the client was not documented on any of the release forms.
Client #2 was admitted on September 7, 2021 and was discharged on October 26, 2021. There were release of information forms to a physician, a funding source, a case management program, another treatment provider, and an emergency contact that were all signed and dated by the witness on September 10, 2021; however, the dated signature of the client was not documented on any of the release forms.
Client #3 was admitted on June 22, 2021 and was discharged on November 1, 2021. There were release of information forms to a funding source, a probation and parole agency, a caseworker, a youth advocate, and an emergency contact that were all signed and dated by the witness on July 6, 2021; however, the dated signature of the client was not documented on any of the release forms.
Client #5 was admitted on September 16, 2021 and was discharged on January 11, 2022. There were release of information forms to a funding source, a case management program, a probation and parole agency, and an emergency contact that were all signed and dated by the witness on September 17, 2021; however, the dated signature of the client was not documented on any of the release forms.
Client #6 was admitted on September 22, 2021 and was active at the time of inspection. There were release of information forms to a funding source, a probation and parole agency, a dispensary, and an attorney that were all signed and dated by the witness on September 23, 2021; however, the dated signature of the client was not documented on any of the release forms.
Client #7 was admitted on November 23, 2021 and was active at the time of inspection. There were release of information forms to a funding source, an emergency contact, and a court that were all signed and dated by the witness on December 6, 2021; however, the dated signature of the client was not documented on any of the release forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consents are obtained via adobe sign by the ACM. The ACM reviews the consent with the client, obtains a signature from the client, and then the ACM signs as a witness. It was discovered that the ACM was signing as a witness on the consent form in the electronic health record and the client was signing on the adobe sign PDF version of the consent form. The ACM has since been trained to ensure that the adobe sign PDF has the dated client signature and the witness signature, and then it is uploaded into the client record. Corrected consents have been completed for client #2, #3, #5, and #6. Clinical Coordinator implemented a tracking system to ensure all consents are completed properly and updated prior to date of expiration. Clinical Coordinator will also monitor to ensure the adobe sign PDF with the witness and dated client signature is uploaded correctly into the client's record. Clinical Coordinator and Clinical Supervisor will monitor weekly to ensure that we are in compliance with confidentiality laws and regulations. In addition, the Clinical Manager will monitor monthly to ensure compliance. |
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 document the written acknowledgement by clients that they have been notified that a client receiving care of treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by status and that no client may be deprived of a civil right solely by reason of treatment in seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Civil Rights Compliance form holds the language specfic to "No person may be deprived fo a civil right solely by reason of treatment." All 7 client records have evidence of the client reviewing and acknowledging the form which contains this language. Unfortunately, during the course of this inspection, a different form was presented which was an outdated form, giving the appearance that the form did not include the necessary civil rights and liberties statement. All forms have been updated and old forms purged at the facility to ensure the wrong form is not presented again. At the time of admission, all clients will be provided with the client rights document to review and acknowledge. The signed client rights document will be uploaded into the client chart. Clinical Coordinator will also monitor to ensure the client rights document is uploaded correctly into the client's record. Clinical Coordinator and Clinical Supervisor will monitor weekly to ensure that we are in compliance with laws and regulations. In addition, the Clinical Manager will monitor monthly to ensure compliance. |
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 document the written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in seven of seven client records reviewed.
The client rights and responsibilities acknowledgement document, for all clients records reviewed, was missing color, ethnicity, and marital status.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility's Civil Rights form and the Client Rights and Responsibilities form includes language specific to 709.30. Both forms are provided to each client at admission. During the time of the inspection, an old form from 2004 was presented to the inspector which did not include this language. However, the form was updated in 2014 and contains the language consistent with 709.30. The 2014 form is the form presented to clients for their review and acknowledgement. As a correction, all old forms have been removed and purged so this error can not happen again. At the time of admission, all clients will continue to be provided with the most up to date client rights document to review and acknowledge. The signed client rights document will be uploaded into the client chart. Clinical Coordinator will also monitor to ensure the client rights document is uploaded correctly into the client's record. Clinical Coordinator and Clinical Supervisor will monitor weekly to ensure that we are in compliance with laws and regulations. In addition, the Clinical Manager will monitor monthly to ensure compliance. Further, all 7 records have an acknowledgement from the client, showing review of form containing appropriate language. |
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 document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility does have a policy which documents the client right to appeal; however, the facility failed to obtain written acknowledgement by the client. As a correction, the facility updated the Client Rights and Responsibilities form to include language about right to appeal a decision limiting acces to their records. This form will be presented upon admission to every client to review and acknowledge. The signed client rights document will be uploaded into the client chart. Clinical Coordinator will also monitor to ensure the client rights document is uploaded correctly into the client's record. Clinical Coordinator and Clinical Supervisor will monitor weekly to ensure that we are in compliance with laws and regulations. In addition, the Clinical Manager will monitor monthly to ensure compliance. The program will ensure all 7 records reflect acknoweldgement of the new Client Rights and Responsibilities language. |
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 document the written acknowledgement by clients that they had been informed of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility has a policy which documents the righ to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records; however, the facility failed to obtain written acknowledgement by the client. As a correction, the facility updated the Client Rights and Responsibilities form to include language specific to 709.30(5) clients have the right to request the corection of inaccurate, irrelevant, outdated or incomplete information in their records. At the time of admission, all clients will be provided with the client rights document to review and acknowledge. The signed client rights document will be uploaded into the client chart. Clinical Coordinator will also monitor to ensure the client rights document is uploaded correctly into the client's record. Clinical Coordinator and Clinical Supervisor will monitor weekly to ensure that we are in compliance with laws and regulations. In addition, the Clinical Manager will monitor monthly to ensure compliance. Further, the program will ensure all 7 records reflect acknoweldgement of the new Client Rights and Responsibilities language. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of a death or serious injury due to trauma, suicide, medication error or unusual circumstances.
On December 6, 2021, the facility was notified of the off-site death of a client; however, there was no documentation that the incident was reported to the Department within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Director provided a training to the Clinical Coordinator, Clinical Manager, and Clinical Supervisors on reporting unusal incidents and provided the provider alert 02-2018 that outlines the procedures for reporting. The Clinical Coordinator will obtain assistance from DDAP in creating Login information for electronic submission of unusual incidents to ensure ease of submission. The Clinical Coordinator will file a report to the Department within 3 buisness days after learning of a death or serious injury due to trauma, suicide, medication error or unusal circumstance. The Clinical Coordinator will submit the report to the Facility Director/Regional Director and Regional Director will ensure the report was filed with the Department. All incidents are then submitted to the Incident Manager; the Incident Manager will track if any unusual incident was submitted to the Department. Further, the Project Director and Quality Management Committee will monitor monthly to ensure compliance with this requirement. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire or ambulance personnel.
On September 10, 2021, the police were called to the facility; however, there was no documentation that the incident was reported to the Department within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director/Regional Director provided a training to the Clinical Coordinator, Clinical Manager, and Clinical Supervisors on reporting unusal incidents and reviewed the provider alert 02-2018 that outlines the procedures for reporting an event that requires the presence of an ambulance. The Clinical Coordinator will obtain assistance from DDAP in creating Login information for electronic submission of unusual incidents to ensure ease of submission. The Clinical Coordinator will file a report to the Department within 3 buisness days after learning of an event at the facility requiring the presence of police, fire, or ambulance personnel. The Clinical Coordinator will submit the report to the Regional Director and Regional Director will ensure the report was filed with the Department. All incidents are then submitted to the Incident Manager; the Incident Manager will track if any unusual incident was submitted to the Department. Further, the Project Director and Quality Management Committee will monitor monthly to ensure compliance with this requirement. |
709.34 (c) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on review of the facility ' s unusual incident reports, the facility failed to notify the Department within 3 business days of an outbreak of a contagious disease requiring CDC notification.
On December 22, 2021 and December 28, 2021, the facility was notified of positive Covid-19 cases among staff; however, there was no documentation that these incidents were reported to the Department within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Director provided a training to the Clinical Coordinator, Clinical Manager, and Clinical Supervisors on reporting unusal incidents and reviewed the provider alert 02-2018 that outlines the procedures for reporting an outbreak of a contagious disease requiring CDC notification. The Clinical Coordinator will obtain assistance from DDAP in creating Login information for electronic submission of unusual incidents to ensure ease of submission. The Clinical Coordinator will file a report to the Department within 3 buisness days after learning of an outbreak of a contagious disease requiring CDC notification. The Clinical Coordinator will submit the report to the Regional Director and Regional Director will ensure the report was filed with the Department. Further, the Project Director and Quality Management Committee will monitor monthly to ensure compliance with this requirement. |
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 ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in two of four applicable client records reviewed.
Client #3 was admitted on June 22, 2021 and was discharged on November 1, 2021. The comprehensive treatment plan was completed on August 3, 2021, and the next treatment plan update was due no later than October 3, 2021; however, the update was not completed prior to discharge.
Client #5 was admitted on September 16, 2021 and was discharged on January 11, 2022. The comprehensive treatment plan was completed on October 22, 2021, and the next treatment plan update was due no later than December 22, 2021; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was discovered that the discharge was not completed timely as client #3 was not engaging in services, therefore the discharge should have been completed prior to the updated treatment being due. The Clinical Coordinator will maintain a tracking mechanism to monitor and ensure complaince with timeliness for treatment plan updates. The Clinical Coordinator will track weekly initial and master treatment that are needed. Treatment plan due dates for each client on their caseload will be emailed to all clinical staff on a weekly basis. For any outstanding treatment plans, the Clinical Coordinator will follow-up with staff to determine whether the client is pending discharge and requires discharge paperwork to be completed. The Clinical Manager will review monthly for compliance. In addition, the Clinical Coordinator will complete a refresher training on completing timely discharges. The Clinical Manager will also track and monitor timliness of discharges to ensure compliance within the agency's policies. Project Director will additional ensure compliance by reviewing the tracker on a monthly basis with Clinical Manager and team. |
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, the facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in four of six applicable client records reviewed.
Client #1 was admitted on August 17, 2021 and was discharged on October 22, 2021. The comprehensive treatment plan dated August 24, 2021, specified weekly individual counseling services. There was no documentation, in the record, of individual counseling services occurring the weeks of September 19, 2021 through discharge.
Client #4 was admitted on September 20, 2021 and was discharged on December 23, 2021. The comprehensive treatment plan dated November 4, 2021, specified weekly individual counseling services. There was no documentation, in the record, of individual counseling services occurring the weeks of November 7, 2021 - November 13, 2021 and November 21, 2021 - December 4, 2021.
Client #5 was admitted on September 16, 2021 and was discharged on January 11, 2022. The comprehensive treatment plan dated October 22, 2021, specified weekly individual counseling services. There was no documentation, in the record, of individual counseling services occurring the weeks of November 21, 2021 - November 27, 2021 and December 19, 2021 through discharge.
Client #6 was admitted on September 22, 2021 and was active at the time of inspection. The comprehensive treatment plan dated October 28, 2021, and treatment plan updates dated December 21, 2021, January 25, 2022, and March 22, 2022, all specified weekly individual counseling services. There was no documentation, in the record, of individual counseling services occurring the weeks of February 20, 2021 - February 26, 2022, March 13, 2021 - March 19, 2022, April 10, 2022 - April 16, 2022, April 24, 2022 - April 30, 2022, and May 8, 2022 - May 14, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For client #4, #5, and #6, the client and counselor mutually agreed to not schedule an appointment during those times due to scheduled time off and holidays. The counselors did not document in the client record that they were not meeting those weeks as indicated in the treatment plan. In addition, it was not included in the treatment plan that there may be certain weeks of the year such as holidays and vacations that the counselor and/or client will be unable to meet for treatment. Administrative progress notes will document missed sessions. It was also discovered that client #1 was not discharged timely. The Clinical Manger will audit charts monthly to ensure documentation is completed in client charts to reflect any service appointments not being held in accordance to the treatment plan recommended scheduling frequency. The Clinical Coordinator will train staff to include in the treatment plan that there may be mutually agreed upon weeks that the counselor and client may not meet. The Clinical Coordinator will follow up with clinical staff to ensure discharges are completed within a timely manner to reduce duration between last completed service appointment and a client's discharge. Facility Director will ensure compliance via weekly supervision with Clinical Manager and team. |
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 a maintain a complete client record on an individual, which is to include follow-up information, in four of five applicable client records reviewed.
Client #1 was admitted on August 17, 2021 and was discharged on October 22, 2021. There was no documentation of follow-up in the record.
Client #3 was admitted on June 22, 2021 and was discharged on November 1, 2021. There was no documentation of follow-up in the record.
Client #4 was admitted on September 20, 2021 and was discharged on December 23, 2021. There was no documentation of follow-up in the record.
Client #5 was admitted on September 16, 2021 and was discharged on January 11, 2022. There was no documentation of follow-up in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current policies reflects that follow-up information will be obtained for all discharges, however, follow-up information was only being obtained for successful discharges. Client #3, #4, and #5 were all discharged for non-complaince and follow-up information was not obtained. The policies and procedures for follow-up information will be reviewed and updated to reflect that follow-up information will be obtained for all successful discharges. Regional Director and Clinical Coordinator developed a more robust tracking mechanism to ensure timely completion of follow-up phone calls post-discharge that is in line with the agencie's policies and procedures. The names of each client successfully completing treatment will be provided to the Administrative Case Manager, who will then complete the aftercare follow-up call. The Clinical Coordinator and Clinical Supervisor will monitor timely completion of follow-up phone calls for all discharged clients. The Clinical Manager will provide oversight monthly to ensure compliance with case consultation notes. Clinical Manager and Clinical Coordinator will review policy with all staff completing follow-up phone calls to ensure timeliness of completion. |