INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 17, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Adappt Outpatient Treatment Services 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 a review of personnel records, the facility failed to ensure that clinical supervisors and lead counselors, who have not functioned for 2 years as a supervisor in the provision of clinical services, completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed.
Employee #3 was promoted to lead counselor on February 22, 2021. There was no documentation of clinical supervision experience prior to being hired and no documentation that the clinical supervision core curriculum training was completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will ensure all lead staff or clinical supervisors have completed clinical supervision training within one year. Current lead counselor will complete training by 6/30/22. Project Director will review training semi-annually. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of one applicable personnel record reviewed.
Employee # 4 was hired as a counselor on December 2, 2020 and was due to have the HIV/AIDS training no later than December 2, 2021. The HIV/AIDS training was not completed at the time of the inspection.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
Facility Director will ensure all staff receive required hours of HIV/AIDS and tuberculosis, sexually transmitted diseases and other health topics within the first year of employment. Current employee is scheduled for training on 3/16 ? 3/17/22. Project Director will review training completed semi-annually. |
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 a dated signature of the client on release of information forms in seven of seven client records reviewed.
Every consent to release information form in each client record reviewed failed to document the dated signature of the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project's informed and voluntary consent form shall be signed by all Clients beginning on 3/18/22. Staff will be trained ensuring signatures are completed on all consents by the facility director. Additionally, by 3/18/22, a plan will be put into place to ensure barriers to signature, such as COVID-19, are managed and signed consents are received. The Facility Director will review files to ensure compliance monthly. |
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 provide treatment plan updates within the regulatory timeframe in two of three applicable client records reviewed.
Client #1 was admitted October 6, 2021 and was active at the time of inspection. A comprehensive treatment plan was completed on November 9, 2021, and the first update was due no later than January 9, 2022. However, the update was completed on January 25, 2022.
Client #6 was admitted on January 20, 2021 and was discharged on August 3, 2021. A treatment plan update was completed on May 7, 2021, and the next update was due no later than July 7, 2021. However, the update was not completed prior to the client's discharge.
This finding was discussed with facility staff during the licensing process.
This is a repeat citation from the February 25, 2021 and February 13, 2020 annual licensing inspections.
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Plan of Correction
Facility Director will review Treatment Plan Policies & Procedures with staff by 3/18/22 and will conduct monthly file reviews to ensure compliance. Treatment plan review for Client #1 was completed on 1/9/22 and again on 3/9/22. |
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 a maintain a complete client record on an individual, which is to include a discharge summary, in two of three applicable client records reviewed.
Client #4 was admitted on July 20, 2021 and was discharged on September 29, 2021. There was no documentation of a completed discharge summary as of the date of the inspection.
Client #5 was admitted on March 12, 2021 and was discharged on June 12, 2021. There was no documentation of a completed discharge summary as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the February 25, 2021, February 13, 2020, January 14, 2019, and May 8, 2018 annual licensing inspections.
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Plan of Correction
Facility Director will revise SDTP discharge policy to include a Discharge Summary document for every chart. Director will conduct monthly file reviews of discharged files to ensure compliance. |
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 one of three applicable client records reviewed.
Client #6 was admitted on January 20, 2021 and was discharged on August 3, 2021. There was no documentation of follow-up information in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the February 25, 2021, February 13, 2020, January 14, 2019, May 8, 2018, and February 22, 2017 annual licensing inspections.
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Plan of Correction
Facility Director will review DDAP Post Discharge Communication Policy with staff by 3/18/22. Director will conduct monthly file audits to ensure compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for follow-up information were submitted and approved by the Department for the February 25, 2021, February 13, 2020, January 14, 2019, May 8, 2018, and February 22, 2017 annual licensing inspections. Follow-up information was again found to be a deficiency in the February 17, 2022 licensing inspection.
Plans of correction for discharge summaries were submitted and approved by the Department for the February 25, 2021, February 13, 2020, January 14, 2019, and May 8, 2018 annual licensing inspections. Discharge summaries were again found to be a deficiency in the February 17, 2022 licensing inspection.
Plans of correction for treatment plan updates were submitted and approved by the Department for the February 25, 2021 and February 13, 2020 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the February 17, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and Facility Director will train on follow-up communication, treatment plan update regulations and discharge summary documentation by March 18, 2022. Staff will begin submitting treatment plan updates to the Facility Director for review in advance of the required deadline. The Facility Director will complete file review of all active files until such time we are confident the requirements are being met, at which time the Facility Director will complete regular fidelity review of active files to ensure compliance and ensure POC is followed. Any file found to not have a treatment plan update will have corrected and the staff will complete performance improvement plan.
The Project Director and Facility Director will train on 30 day contact regulation by March 18, 2022. Facility Director will also place a 30 day follow up reminder in Staff's calendars to remind them to contact successful reentrants. After the contact, staff will forward the post completion contact document to the Facility Director for review. The Facility Director will complete file review of all active files until such time we are confident the requirements are being met, at which time the Facility Director will complete regular fidelity review of active files to ensure compliance and ensure POC is followed. Any file found to not have a 30 day contact update will have corrected and the staff will complete performance improvement plan.
The Project Director and Facility Director had misidentified forms we understood to be sufficient to satisfy to requirement for discharge summaries. Doing so created the incorrect application to prior POC. Staff will be trained on the use of the proper discharge summary form to be utilized and applicable requirements by March 18, 2022. Staff will begin utilizing the discharge summary and follow the requirement by March 18, 2022. The Facility Director will complete file review of all discharges until such time we are confident the requirements are being met at which time the Facility Director will complete regular fidelity review of files at discharge to ensure compliance and ensure POC is followed.
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