INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection conducted on December 17, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Sojourner House, 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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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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven records reviewed.
Client #1 was admitted on May 14, 2024, and discharged on September 19, 2024. A release of information form to bill insurance for services was not documented in the record.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the March 7, 2024, annual inspection.
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Plan of Correction
The clinical supervisor on 1/10/25 met with the intake staff, counselors, and service coordinators. They have been instructed to get a release of information consent from all insurance agencies to ensure proper consent is given when providing treatment services. The clinical supervisor will audit charts weekly to ensure proper documentation is being provided. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment plans at least every 30 days in seven of seven records.
Client #1 was admitted on May 14, 2024, and discharged on September 19, 2024. A treatment plan update was completed on June 17, 2024, and the next update was due no later than July 17, 2024; however, it was not completed until July 24, 2024.
Client #2 was admitted on July 25, 2024, and discharged on October 28, 2024. A treatment plan update was completed on September 24, 2024, and the next update was due no later than October 24, 2024; however, it was not completed until October 25, 2024.
Client #3 was admitted on May 21, 2024, and discharged on September 17, 2024. A treatment plan update was completed on June 24, 2024, and the next update was due no later than July 24, 2024; however, it was not completed until August 2, 2024.
Client #4 was admitted on May 20, 2024, and discharged on October 8, 2024. A treatment plan update was completed on June 28, 2024, and the next update was due no later than July 28, 2024; however, it was not completed until August 2, 2024.
Client #5 was admitted on August 16, 2024, and was still active at the time of the inspection. A treatment plan update was completed on September16, 2024, and the next update was due no later than October 16, 2024; however, it was not completed until November 26, 2024.
Client #6 was admitted on September 18, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 20, 2024. A treatment plan update was due October 20, 2024, and was not completed until October 21, 2024.
Client #7 was admitted on October 2, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was developed on October 7, 2024. A treatment plan update was due November 7, 2024, and was not completed until November 12, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 7, 2024, annual inspection.
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Plan of Correction
Sojourner House has added a notification feature to the ERS. The feature will give the clinical staff a 3 day notice when treatment plan updates are due. The clinical supervisor will also monitor charts weekly and give a verbal notification when updates need completed.The clinical staff are to bring their client list to treatment team meetings weekly to discuss client reviews to ensure we are compliant to DDAP regulations for treatment plan reviews. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 document case consultations in six of seven records.
The facility's policy and procedure manual states a case consultation must be completed monthly.
Client #1 was admitted on May 14, 2024, and discharged on September 19, 2024. There were no case consultations notated in client #1 ' s record for the months of June and July 2024.
Client #3 was admitted on May 21, 2024, and discharged on September 17, 2024. There were no case consultations notated in client #3 ' s record for the months of June, July, and August 2024.
Client #4 was admitted on May 20, 2024, and discharged on October 8, 2024. There were no case consultations notated in client #4 ' s record for the months of July, August, and September 2024.
Client #5 was admitted on August 16, 2024, and was still active at the time of the inspection. There were no case consultations notated in client #5 ' s record for the months of September and November 2024.
Client #6 was admitted on September 18, 2024, and was still active at the time of the inspection. There were no case consultations notated in client #6 ' s record for the months of October and November 2024.
Client #7 was admitted on October 2, 2024, and was still active at the time of the inspection. There were no case consultations notated in client #7 ' s record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 7, 2024, annual inspection.
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Plan of Correction
Sojourner House has added a notification feature to the ERS. The feature will give the clinical staff a 3 day notice when client case consultations are due. The clinical supervisor will also monitor charts weekly ensure consultations are documented within the timeframes outlined in our policies and procedures manual. Sojourner Administration staff realized the wrong treatment manual was submitted for the audit. The policy and procedures indicates Sojourner House will complete a consultation every 90 days. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 document follow-up information in two of four discharged records.
The facility's policy and procedure manual states follow up contact is to be completed for all discharges within 7 days.
Client #1 was admitted on May 14, 2024, and discharged on September 19, 2024. There was no follow up information documented in client #1 ' s record.
Client #3 was admitted on May 21, 2024, and discharged on September 17, 2024. Follow up was due no later than September 24, 2024; however, it was not completed until September 25, 2024.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 7, 2024, annual inspection.
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Plan of Correction
Sojourner House has added a notification feature to the ERS. The feature will give the clinical staff a 3 day notice when 7 day follow-ups are due. Counselors and service coordinators have been given a file audit form to be completed every month documenting what document have been completed to be reviewed during treatment team meetings The clinical will track and monitor client discharges to ensure 7 day follow-ups have been completed. |