INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24, 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. There was a fire extinguisher located in the lower-level chart room that was last inspected in September 2020.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Facility Director will notify the internal maintenance manager and fire extinguisher company of the expired fire extinguisher. The expired fire extinguisher will be added to the list of building fire extinguishers that need to be reviewed and inspected on an annual basis. For the current expired fire extinguisher, the fire extinguisher company was notified and inspected the fire extinguisher on 6/21/2022. The building EOC representative will monitor and document fire extinguisher compliance using the quarterly inspection report. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's May 2021 through April 2022 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills. The facility utilized the front door exit route during all reviewed fire drills conducted.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Facility EOC representative conducting the fire drills will be responsible for using alternate routes, including the following exits: the front door of the building, the side door facing 69th street and the back door facing the back alley. The alternate exits will offer clients and employees several safe options to exit the building in the event of a fire. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's May 2021 through April 2022 fire drill log, the facility failed to set off a fire alarm or smoke detector during each fire drill. The facility failed to set off the fire alarm or smoke detector during the December 2021 fire drill.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The facility EOC representative responsible for conducting the monthly fire drills, will set off the fire alarm or smoke detector for each monthly fire drill. This will be monitored by the EOC representative and the facility director. |
709.24 (a) 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:
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to follow their coordination of client treatment and rehabilitation services policies and procedures as it related to the admission and discharge processes.
The facility policy stated that "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."
The facility maintained an active client roster that included clients who did not return to the facility to complete the intake process. Due to the facility not discharging clients who were not considered active clients, three clients were reviewed as active clients and therefore, were missing all the required documentation.
Client # 3 was admitted on March 9, 2022 and was active at the time of the inspection.
Client # 4 was admitted on April 28, 2022 and was active at the time of the inspection.
Client # 7 was admitted on March 28, 2022 and was discharged on April 7, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #3 and #4 were considered open cases when they completed the intake process but never showed or completed the official face-to-face clinical admission. Since treatment did not start, the clients should have been discharged and their cases closed when they failed to show for their official admission. The program coordinator will monitor the weekly scheduled admission evaluations and promptly close client charts when there is no complete admission. Client #7 was discharged but without the official evaluation requirements, this again will be monitored by the program coordinator weekly for compliance. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee, in one of three applicable personnel records reviewed.
Employee #1 was hired as the Project Director on March 4, 2019. The annual written staff performance evaluation, dated May 2, 2022, was not signed by the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Annual evaluations will be reviewed and signed by all employees and their supervisors. Annual evaluation submissions will be monitored electronically through the agency's Ultipro employee management system and Human Resources will run a monthly report of all evaluation submissions and submit to each facility director for review. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, the facility failed to secure hard copy client records within locked storage containers. The chart room door was propped open and there were no authorized personnel in the room at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility EOC representative attends the monthly agency environment of care meeting where she reports on facility needs. The EOC representative will monitor the client records room door, making sure it is closed and locked at all times. This will be monitored by the EOC representative by adding this to her monthly facility report. |
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 client on release of information forms in one of seven client records reviewed.
Client #2 was admitted on July 8, 2021 and was active at the time of inspection. A release of information form to an attorney was signed and dated by the witness on November 3, 2021; however, the dated signature of the client was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Release of Information Forms are typically completed at the time of admission however additional and/or new releases are completed throughout a client's treatment. The facility director will review the release of information procedure during group supervision meeting on 6/23/2022. Ongoing monitoring of releases will be reviewed during monthly client chart audits completed by the program coordinator. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the witness on release of information forms in one of seven client records reviewed.
Client #2 was admitted on July 8, 2021 and was active at the time of inspection. A release of information form to a probation and parole agency was signed and dated by the client on October 7, 2021; however, the dated signature of the witness was not documented
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will review the Release of Information Forms procedure during group supervision on 6/24/2022, to include the need for client and witness signatures on all releases. The program coordinator will review monthly for 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 one of two applicable client records reviewed.
Client #1 was admitted on July 30, 2021 and was active at the time of inspection. The client rights acknowledgement document, in the client record, did not include notification of this regulatory client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility does have a client rights document that is provided to each client at admission. It was discovered that the facility's client rights document was missing the language pertaining to clients rights regarding civil rights and liberties. The client rights document has been updated to reflect that each client receiving treatment shall retain civil rights and liberties except as provided by statute. No client will be deprived of a civil right solely by reason of treatment. 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. The program coordinator will monitor to ensure the client rights document is uploaded into the client's record and 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 two of two applicable client records reviewed.
Client #1 was admitted on July 30, 2021 and was active at the time of inspection. The client rights and responsibilities acknowledgement document was missing color, ethnicity, and marital status.
Client #2 was admitted on July 8, 2021 and was active at the time of inspection. The client rights and responsibilities acknowledgement document 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 does have a client rights document that is provided to each client at admission. It was discovered that the facility's client rights document was missing the language pertaining to clients rights regarding discrimination on the basis of color, ethnicity and marital status. The client rights document has been updated to reflect that no client shall be discriminated against on the basis of age, race, color, ethnicity, religion, creed, gender, sexual orientation, national origin, handicap, marital status, or drug of choice. 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. The program coordinator will monitor to ensure the document is uploaded into the client chart and monitor monthly for compliance. |
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 written acknowledgement by clients that they had been informed of their right to appeal a decision limiting access to their records to the director in two of two applicable client records reviewed.
Client #1 was admitted on July 30, 2021 and was active at the time of inspection. The client rights acknowledgement form, in the client record, did not include notification of this regulatory client right.
Client #2 was admitted on July 8, 2021 and was active at the time of inspection. The client rights acknowledgement form, in the client record, did not include notification of this regulatory client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility does have a client rights document that is provided to each client at admission. It was discovered that the facility's client rights document was missing the language pertaining to client rights regarding the right to an appeal. The client rights document has been updated to reflect that each client will have the right to appeal a decision limiting access to their records and appeals will be reviewed and monitor by the facility director. 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 and monitored by the program coordinator. The program coordinator will monitor client charts monthly for compliance. |
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 written acknowledgement by clients that they had been informed of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records in two of two applicable client records reviewed.
Client #1 was admitted on July 30, 2021 and was active at the time of inspection. The client rights acknowledgement form, in the client record, did not include notification of this regulatory client right.
Client #2 was admitted on July 8, 2021 and was active at the time of inspection. The client rights acknowledgement form, in the client record, did not include notification of this regulatory client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility does have a client rights document that is provided to each client at admission. It was discovered that the facility's client rights document was missing the language pertaining to clients rights regarding correction of inaccurate information. The client rights document has been updated to reflect that each client will have the right to request the correction 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 and the program coordinator will monitor to ensure it was uploaded correctly and monitor charts monthly to ensure compliance. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the facility failed to develop an efficient data collection and recordkeeping system that showed the facility's admitted clients, per their stated policy.
The facility policy stated that "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." However, the facility maintained an active client roster that included clients who did not return to the facility to complete the intake process.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was discovered that several clients remained "Active" despite their failure to return to the facility to complete the face-to-face clinical evaluation. The program coordinator will monitor the weekly "Intake" appointments and scheduled evaluations dates and discharge clients in a more timely fashion if they fail to report to their scheduled evaluation appointment. The program coordinator will document any outreach calls if the client needs to reschedule their initial evaluation appointment prior to discharging them. |
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 three of three applicable client records reviewed.
Client #2 was admitted on July 8, 2021 and was still active at the time of inspection. A treatment plan update was completed on September 21, 2021, and the next update was due no later than November 21, 2021; however, the update was completed on April 27, 2022.
Client #5 was admitted on April 13, 2021 and was discharged on February 28, 2022. A treatment plan update was completed on August 31, 2021, and the next update was due no later than October 31, 2021; however, the update was not completed prior to discharge.
Client #6 was admitted to on April 8, 2021 and was discharged on April 18, 2022. A treatment plan update was completed on September 28, 2021, and the next update was due no later than November 28, 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 in Client #2,Client #5, and Client #6 clinical charts, that treatment plans were not reviewed and updated every sixty days. The program coordinator will maintain a treatment plan tracker to monitor and ensure compliance with timeliness for treatment plan updates. The program coordinator will track initial and master treatment plans that are needed and email treatment plan due dates to each clinician on a weekly basis. The program coordinator will complete consistent chart audits and review the regulations during group supervision meeting schedule for 7/7/2022. |
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 three of four applicable client records reviewed.
Client #1 was admitted on July 30, 2021 and was active at the time of inspection. The preliminary treatment plan, dated August 11, 2021, specified five individual counseling services per week. There was no documentation, in the client record, of individual counseling services occurring the weeks of September 5, 2021 through the time of inspection.
Client #5 was admitted on April 13, 2021 and was discharged on February 28, 2022. The treatment plan update, dated August 31, 2021, specified weekly individual counseling services. There was no documentation, in the client record, of individual counseling services occurring the weeks of October 10, 2021 through discharge.
Client #6 was admitted on April 8, 2021 and was discharged on April 18, 2022. The treatment plan update, dated September 28, 2021, specified weekly individual counseling services. There was no documentation, in the client record, of individual counseling services occurring the weeks of December 5, 2021 - December 18, 2021, December 26, 2021 - January 1, 2022, January 16, 2022 - January 22, 2022, and February 27, 2022 - March 5, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was discovered that Client #1 and Client #5 were not discharged timely and there was no documentation to support the lapse in the client records. It was also discovered that Client #6 had several weeks of clinical lapse and no documentation to support reasons why there were no clinical sessions. Moving forward, the program coordinator 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 program 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 program coordinator will follow up with clinical staff to ensure discharges are completed with a timely manner to reduce duration between last completed service appointment and a client's discharge. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include case consultation notes, in four of four applicable client records reviewed.
Client #1 was admitted on July 30, 2021 and was active at the time of inspection. There was no documentation of case consultation notes during the treatment episode.
Client #2 was admitted on July 8, 2021 and was active at time of inspection. There was no documentation of case consultation notes during the treatment episode.
Client #5 was admitted on April 13, 2021 and was discharged on February 28, 2022. There was no documentation of case consultation notes during the treatment episode.
Client #6 was admitted on April 8, 2021 and was discharged on April 18, 2022. There was no documentation of case consultation notes during the treatment episode.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was discovered that there were no case consultation notes in the clinical charts for Clients#1, 2, 5,6. The program coordinator will review regulations with the clinical staff during group supervision on 7/7/2022 reminding them to include case consultation notes and documentation to include in the client charts. Case consultation notes will include but are not limited to consultation with internal and external agencies such as PCP, probation, psychiatry, etc. The program coordinator will complete monthly audits to monitor for compliance. |
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 maintain a complete client record, which is to include a discharge summary, in two of three applicable client records reviewed.
Client #5 was admitted on April 13, 2021 and was discharged on February 28, 2022.
Client #7 was admitted on March 28, 2022 and was discharged on April 7, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was discovered that discharge summaries were not completed at the time of the client's discharge in Client #5 and Client #7 charts. The program coordinator will review this requirement with the clinicians during group supervision meeting on 7/7/2022 and continue to monitor through monthly chart audits. |
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 maintain a complete client record, which is to include follow-up information, in three of three applicable client records reviewed.
Client #5 was admitted on April 13, 2021 and was discharged on February 28, 2022.
Client #6 was admitted on April 8, 2021 and was discharged on April 18, 2022.
Client #7 was admitted on March 28, 2022 and was discharged on April 7, 2022.
This is a repeat citation from the May 17, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current policy reflects that follow-up information will be obtained for all discharges, however, follow-up information was not captured for the three client charts reviewed by the auditor. Clients #5 and #6 were discharged for non-compliance and no additional follow-up outreach was documented. Client #7 never attended his first face-to-face evaluation appointment and no additional follow-up outreach was documented. The facility director will review the policy and procedures with employees during group supervision on 6/23/2022 to include outreach follow-up information. This will be monitored by the program coordinator during monthly chart audits in order to ensure compliance. |