INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CHMH Services PA LLC DBA Charlie Health 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(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on one of one applicable employee personnel records reviewed, the facility failed to provide documentation of at least two years' experience or the completion of a core curriculum in clinical supervision for employee # 2.
Employee # 2 was hired as a clinical supervisor on August 1, 2022 and was still in this position at the time of the inspection. Based on employee # 2's resume, there was no documentation of at least two years ' experience or the completion of a core curriculum in clinical supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Manager reached out to the PA State Licensing specialist on June 12th 2023 to acquire state approved Clinical Supervisor DDAP Trainings that satisfy the state facility licensing requirements. Charlie Health utilized Relias Training Academy as their training platform and has added the Clinical Supervisor Training Bundle that was provided as approved training by the PA State Licensing Specialist. The Clinical Supervisor completed the Core Curriculum Clinical Supervision training on June 14th 2023. Charlie Health has added the training bundle to the Staff Develop Plan to ensure that all Clinical Supervisors in PA receive this training moving forward as required. Charlie Healths Training team will audit personnel records annually for continued monitoring for all required trainings to ensure ongoing compliance. |
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 the review of the facility's fire drill log for the months of Juy 2022 through May 2023, the facility failed to maintain a written fire drill record that included the exit route used on all fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/24/23 the Compliance Manager completed an edit to the Fire Drill Form that is completed monthly. Once a fire drill is conducted the Drill is documented through Google Forms. The Google Forms was edited to include "Exit Route Used". The Compliance Manager will continue to monitor on a monthly basis that a Fire Drill and Form is completely entirely to include the "fire exit used" when the fire drill was conducted. |
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 two of two client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 1 and 2.
Client # 1 was admitted on December 19, 2022 and was discharged on March 17, 2023. A review of client records and discussion with facility administration indicated funding was being provided to the client. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.
Client # 2 was admitted on August 22, 2022 and was discharged on October 14, 2022. A review of client records and discussion with facility administration indicated funding was being provided to the client. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Manager and Director of Health Information met on 6/14/23 to discuss the findings during the inspection. During the Admissions process our Clinical Intake team has created a process to receive Releases of Information from the Client and Parent/ Guardian. The Release of Information for the funding source will now be a required disclosure at admissions of 6/16/23. The Health Information Team has implemented a new process to receive a weekly report from Salesforce to be notified of all new Pennsylvania SUD Clients. The Director of Health Information trained the Health information team on 6/22/23 on the new process to obtain the "Funding Source Disclosure of information". To ensure ongoing compliance the Quality Audit team has added the Disclosure of Information for the funding source to their monthly audits and will report to the Health information and Compliance team on the compliance rate. |
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 two of two client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure
Client # 1 was admitted on December 19, 2022 and was discharged on March 17, 2023. An informed and voluntary consent from the client for the disclosure of information dated December 19, 2022 to an emergency contact did not include the purpose of the disclosure.
Client # 2 was admitted on August 22, 2022 and was discharged on October 14, 2022. An informed and voluntary consent from the client for the disclosure of information dated August 23, 2022 to an emergency contact did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Manager and Director of Health Information met on 6/14/23 to discuss the findings during the inspection. The Health Information Team reviews 100% of consent packets once they are signed during each clients admission process. The authorization to release information (ROI) forms are audited for validity. When an ROI is missing required information such as the "purpose of disclosure" a clarification is sent to the signer via Congasign( an electronic signing platform) transactions referencing the information available in Salesforce. Once a valid Release of information is obtained, the status is updated in Salesforce and the completed form is uploaded to the client account in Charlie Healths Electronic Medical Records System. The Director of Health information has trained the Health Information team on the process to obtain the completed Release of information. To ensure ongoing compliance the Health information team will continue to monitor their process for the Release of information audits to ensure 100% compliance. The Quality Team will continue to audit on a quarterly basis and report their compliance rate to the Health Information and Compliance Team. |