INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Central Behavioral 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #3 was instructed in the use of fire extinguishers upon staff employment within the regulatory timeframe.Employee #3 was hired as a counselor on November 23, 2020 and did not have the training until July 13, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will conduct fire extinguisher training on the first day that the employee starts their position. The training information and sign off sheet has been added to the onboarding packet that all new hires receive. |
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 the review of client records, the facility failed to document a completed informed and voluntary consent to release information form in one out of three client records reviewed, as the form did not include a dated client signature. Client #1 was admitted July 8, 2020 and was still active at the time of the inspection. Two consent to release information forms dated June 8, 2020 were to family members and one dated August 10, 2020 was to a family member.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director spoke with counselor of client #1 on 8/25/21 regarding obtaining signature on releases to family members. It was explained that client #1 did not have the ability to complete forms using e-signature due to technology issues and was not comfortable coming to the site to sign paper copies due to covid concerns.
When an attempt to get forms signed by sending them in the mail to be sent back, client #1 said that he would rather rescind the releases to family as he has no use for them. He was offered the ability to reconsider in the future if needed. The counselor of client #1 wrote a contact note acknowledging that the client is rescinding releases to the identified family members.
Given that many clients in the program continue to use telehealth, the following statement has been added to the policy and procedures manual and all staff members have been made aware of the addition.
"All releases are to be completed in full, including a signature. If the client/consumer is on site they can sign a paper or electronic copy. If the client is off site, they will be given the choice to have the records sent to them via secure email to sign electronically, to come in to the agency in person to sign the documents, or paper copies of the forms will be sent to the client/consumer along with a return envelope for them to sign and send back to the agency to be scanned into the electronic file."
The facility director will regularly check the electronic charts of consumers as well as confirm with program staff members to ensure that the above is being followed. |
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 inform the client of all of their rights. The client rights form given to the client did not identify that clients may not be discriminated against on the basis of religion and creed in three out of three records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/25/2021 the Facility Director corrected the Client Rights Form and had the IT department upload it to the electronic medical record system. The language in the updated form now includes:
"The RIGHT to be provided services at this facility and to be refereed for services at other facilities without regard to my age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
The RIGHT to file a complaint of discrimination if I feel I have been discriminated against on the basis of my age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion."
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, that he shall have the opportunity to request reconsideration of a decision terminating treatment in one out of one applicable records reviewed.Client # 3 was admitted on March 29, 2021 and was administratively discharged on May 12, 2021. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/25/21 the facility director amended the program's standard involuntary closing letter to include the following:
"I hope this letter finds you well. The purpose of this letter is to inform you that on (insert date) you were involuntarily discharged from the CORE program due to lack of contact. If at any time in the future you are interested in returning for services you are welcome to contact us at 610 279 9270 to connect with the intake department in order to schedule an assessment.
If you disagree with this decision, you have the opportunity to request reconsideration and can do so by reaching out to us by calling the number above." |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the frequency of treatment and rehabilitation services in their treatment plan in three out of three records reviewed. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director met with counselor on 8/25/21 to relay that treatment plans are to include frequency of treatment. This will be monitored in supervision between facility director and counselor going forward.
Facility director also reached out to the agency's IT department to inquire if it would be possible to add frequency of treatment as a required area when completing treatment plans within the system. |
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 provide a complete client record, which is to include a discharge summary, in one out of two discharged records reviewed.Client #3 was admitted on March 29, 2021 and discharged on May 12, 2021. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director met with counselor assigned to client #3 on 8/25/2021 to discuss completion of discharge summary. Counselor was not aware that clients that only attended an assessment and no follow up appointment would require a discharge summary. Facility director made it clear that all clients who are opened to the program require a discharge summary upon exiting the program.
Facility director will make the completion of discharge summaries a component of supervision going forward. |
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 provide a complete client record, which is to include follow-up information in one out of one applicable discharge records reviewed.Client #2 was admitted on January 31, 2020 and was discharged on Mach 3, 2020. A follow-up was due March 3, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has created a automatically generating report within the electronic medical record system that will notify them to send follow-up letters to clients 6 months after discharge from the program. |