INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 10, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD Lower Merion Counseling 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.
|
Plan of Correction
|
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on the review of personnel records, the facility failed to follow their own policy regarding the mechanism to collect training feedback in two of five applicable personnel records reviewed.
The facility's staff development program policy stated that feedback forms would be done for each completed training.
Employee # 3 was hired as a clinical supervisor on May 4, 2020. There were no training feedback forms documented in the personnel record for the facility's January 2021 through December 31, 2021 training year.
Employee #5 was hired as a counselor on July 31, 2019. There were no training feedback forms documented in the personnel record for the facility's January 2021 through December 31, 2021 training year.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
LMCMS QA Manager, in conjunction with LMCMS D&A Leadership, will develop a new feedback mechanism (online survey) that will be taken by D&A Leadership, Supervisor and Clinicians (including FT, IC, and Intern Clinicians) on a quarterly basis. The new feedback mechanism will be implemented by 4/8/22 and will be used to collect feedback on completed training for CY21 Q1 (Jan ? March '22).
LMCMS D&A Leadership will update the D&A Staff Development Program and its relevant policies to reflect the above changes to the feedback mechanism.
The new feedback mechanism will be reviewed by the Clinical Supervisor and the Clinical Director on a quarterly basis. This quarterly review will reconcile the feedback mechanism against the new staff training transcripts as described below for Citation 704.11(d)(2) as well as against the new training tracking mechanism described below for Citation 704.11(e)(1). First quarterly review of D&A training feedback, tracking, and transcripts will occur by 4/15/2022.
|
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of personnel records, the facility failed to ensure that the project director completed at least 12 clock hours of training during the facility's January 1, 2021 through December 31, 2021 training year.
Employee #1 was hired as the project director on February 18, 2018. The personnel record documented 9 hours of training during the reviewed training year.
This is a repeat citation from the March 2, 2021 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
All trainings completed by LMCMS D&A FT/PT Staff, including the Project Director, whether an internally or externally provided training, will be entered and tracked in RHD's Training Suite to be part of the employee's training transcript. LMCMS will require that any training entered and tracked in this manner will include the amount of time spent in each training, any CEUs awarded, and, if applicable, will require that any awarded training certificates are uploaded and attached to the training record. This will commence by 4/1/2022.
Training transcripts will be reviewed by the Clinical Supervisor and the Clinical Director on a quarterly basis. This quarterly review will reconcile the training transcripts against the new training feedback mechanism described above for Citation 704.11(a)(3) as well as against the new training tracking mechanism described below for Citation 704.11(e)(1). First quarterly review of D&A training feedback, tracking, and transcripts will occur by 4/15/2022.
|
704.11(e)(1) LICENSURE Trng Req-Clinical Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
|
Observations
Based on a review of personnel records, the facility failed to ensure that each clinical supervisor completed at least 12 clock hours of training annually during the facility's January 1, 2021 through December 31, 2021 training year in one of one applicable personnel record reviewed.
Employee # 3 was hired as a clinical supervisor on May 4, 2020. The personnel record documented 6 hours of training received during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
LMCMS D&A Supervisor, in conjunction with the LMCMS QA Manager, will develop a new training tracking mechanism that will track the total hours of completed training for all D&A Clinical Leadership, Supervisor(s) and D&A Clinicians (FT, IC, and Intern). This training tracking mechanism will be fully implemented by 4/1/2022.
The new training tacking mechanism will be reviewed by the Clinical Supervisor and the Clinical Director on a quarterly basis. This quarterly review will reconcile the training tracker against staff training transcripts as described above for Citation 704.11(d)(2) above as well as against the new training feedback mechanism described above for Citation 704.11(a)(3). First quarterly review of D&A training feedback, tracking, and transcripts will occur by 4/15/2022.
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2021 through December 31, 2021 training year in one of one applicable personnel record reviewed.
Employee #5 was hired as a counselor on July 31, 2019. The personnel record documented 9 hours of training received during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
LMCMS D&A Supervisor, in conjunction with the LMCMS QA Manager, will develop a new training tracking mechanism that will track the total hours of completed training for all D&A Clinical Supervisor(s) and D&A Clinicians (FT, IC, and Intern). This training tracking mechanism will be fully implemented by 4/1/2022
The new training mechanism will be reviewed by the Clinical Supervisor and the Clinical Director on a quarterly basis. This quarterly review will reconcile the training tracker against staff training transcripts as described above for Citation 704.11(d)(2) above as well as against the new training feedback mechanism described above for Citation 704.11(a)(3). First quarterly review of D&A training feedback, tracking, and transcripts will occur by 4/15/2022.
|
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on a review of the Staffing Requirement Facility Summary Report, the facility failed to ensure that the FTE counselor caseload for counseling in outpatient programs did not exceed 35 active clients. Ten counselors exceeded the individual 35 to 1 FTE counselor caseload and the overall facility FTE counselor caseload exceeded the 35 to 1 FTE counselor caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, to obtain the FTE ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
The overall facility outpatient counselor caseload ratio calculation was as follows: 50/40= 1.25(FTE); then 64/1.25= 51.2 which equals a client/counselor ratio of 51:1
Employee #4 was hired as a clinical supervisor on April 19, 2021 and was still employed at the time of the inspection. The ratio calculation was as follows: 4/40= 0.1(FTE); 4/0.1= 40 which equals a client/counselor ratio of 40:1.
Employee #5 was hired as a counselor on July 31, 2019 and was still employed at the time of the inspection. The ratio calculation was as follows: 13/40= 0.325 (FTE); 17/0.325= 52.3076 which equals a client/counselor ratio of 52:1.
Employee #6 was hired as a counselor on July 12, 2021 and was still employed at the time of inspection. The ratio calculation was as follows: 11/40= 0.275 (FTE); 16/0.275= 58.1818 which equals a client/counselor ratio of 58:1.
Employee #7 was hired as a counselor on October 25, 2021 and was still employed at the time of inspection. The ratio calculation was as follows: 6/40= 0.15 (FTE); 7/0.15= 46.6667 which equals a client/counselor ratio of 46:1.
Employee #8 was hired as a counselor on June 14, 2021 and was still employed at the time of inspection. The ratio calculation was as follows: 1/40= 0.025 (FTE); 1/0.025= 40 which equals a client/counselor ratio of 40:1.
Employee #9 was hired as a counselor on July 13, 2021 and was still employed at the time of inspection. The ratio calculation was as follows: 4/40= 0.1(FTE); 5/0.1= 50 which equals a client/counselor ratio of 50:1.
Employee #10 was hired as a counselor on February 3, 2021 and was still employed at the time of inspection. The ratio calculation was as follows: 4/40= 0.1(FTE); 4/0.1= 40 which equals a client/counselor ratio of 40:1.
Employee #11 was hired as a counselor on September 6, 2021 and was still employed at the time of inspection. The ratio calculation was as follows: 1/40= 0.025 (FTE); 1/0.025= 40 which equals a client/counselor ratio of 40:1.
Employee #12 was hired as a counselor on April 26, 2021 and was still employed at the time of inspection. The ratio calculation was as follows: 4/40= 0.1(FTE); 4/0.1= 40 which equals a client/counselor ratio of 40:1.
Employee #13 was hired as a counselor on August 23, 2021 and was still employed at the time of inspection. The ratio calculation was as follows: 2/40= 0.05 (FTE); 5/0.05= 100 which equals a client/counselor ratio of 100:1.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
LMCMS D&A Clinical Leadership will recalculate and resubmit FTE client/counselor ratios. The new ratios will be submitted by 4/1/2022.
FTE client/counselor ratios will be tracked and reviewed on a monthly basis by the D&A Clinical Supervisor in clinical supervision with clinicians to ensure the FTE counselor caseloads for outpatient programs do not exceed 35 active clients. This will commence effective 4/1/2022.
|
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.
|
Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in one of nine applicable personnel records reviewed.
Employee # 10 was hired as a counselor on October 5, 2021. The personnel record documented that the training in the use of the fire extinguisher was not completed until January 26, 2022.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
LMCMS QA Manager will retrain D&A Program Leadership on new hire training requirements. New hire training requirements include training staff on the use of the fire extinguisher. This training will occur by 4/15/2022.
LMCMS QA Manager will create a New Hire Onboarding Checklist for Program Leadership use to track compliance with meeting new hire training requirements. This Checklist will be completed and implemented by 4/15/2022.
New hire trainings for FT/PT Clinicians will be entered into and tracked with training transcripts as described above for Citation 704.11(d)(2) as well as in the new training tracking mechanism as described above for Citation 704.11(f)(2).
New hire trainings for IC/Intern Clinicians will be entered and tracked in the training tracking mechanism as described above for Citation 704.11(f)(2).
|
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.
|
Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in seven of seven client records reviewed.
In every client record reviewed, there was evidence of disclosures to the funding sources during each client's treatment episode; however, there were no consent to release information forms, signed by the clients, documented in the records prior to any of the disclosures.
This is a repeat citation from the March 2, 2021 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
LMCMS will use an electronic signature software to capture informed and voluntary consent to release of information for funding sources for every individual open in services as appropriate. These signed releases will by uploaded into their charts by 5/2/2022.
LMCMS will use an electronic signature software to capture informed and voluntary consent to release of information for funding sources as part of intake paperwork to ensure that this consent is obtained prior to commencing services. This signed acknowledgement will be uploaded into individuals' charts. This consent will be included in the intake packet and put into use starting 5/2/2022. Any intake completed prior to that date will have the consent captured through the above mentioned process.
D&A Clinicians will use an electronic signature software to capture complete consents to release of information annually and on as-needed basis. All D&A Clinicians will be trained in the use of the electronic signature software. This training will also cover how to properly complete a Release of Information to be sent out through the electronic signature software for signature. This training will occur by 5/2/2022 and full use of the electronic signature software by D&A Clinicians will roll out by 5/9/2022.
Chart audits will be conducted monthly by the D&A Clinical Supervisor, to include review of informed and voluntary consent to release of information for funding sources. Chart audits will involve no less that one chart reviewed per month. Issues identified through chart audits will be communicated directly with clinicians for rectification and will be used to assess for training needs. Chart audit results will be reviewed at high level on a quarterly basis to identify trends indicating programmatic level changes needed. First round of updated chart audits will be completed 4/30/2022.
|
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.
|
Observations
Based on a review client records, the facility failed to document the purpose of the disclosure on release of information forms in two of seven client records reviewed.
Client # 4 was admitted on May 11, 2021 and was discharged on September 10, 2021. The release of information form to an emergency contact was signed and dated by the client on June 3, 2021, but the form did not document the purpose of the disclosure.
Client # 7 was admitted on October 5, 2021 and was discharged on January 4, 2022. The release of information form to an emergency contact was signed and dated by the client on October 28, 2021, but the form did not document the purpose of the disclosure.
This is a repeat citation from the March 2, 2021 annual licensing inspection.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
LMCMS will use an electronic signature software to obtain updated consents to release of information for the individuals in services identified through the audit. These signed consents will by uploaded into their charts by 5/2/2022.
D&A Clinicians will use the electronic signature software to capture complete consents to release of information annually and on as-needed basis. All D&A Clinicians will be trained in the use of the electronic signature software. This training will also cover how to properly complete a Release of Information to be sent out through the electronic signature software for signature. This training will occur by 5/2/2022 and full use of the electronic signature software by D&A Clinicians will roll out by 5/9/2022.
Chart audits will be conducted monthly by the D&A Clinical Supervisor, to include review of informed and voluntary consent to release of information with purpose of disclosure. Chart audits will involve no less that one chart reviewed per month. Issues identified through chart audits will be communicated directly with clinicians for rectification and will be used to assess for training needs. Chart audit results will be reviewed at high level on a quarterly basis to identify trends indicating programmatic level changes needed. First round of updated chart audits will be completed 4/30/2022.
|
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.
|
Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that 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 and that no client may be deprived of a civil right solely by reason of treatment in seven of seven client records reviewed.
Client #1 was admitted on October 7, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #2 was admitted on May 19, 2021 and was still active at the time of the inspection. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #3 was admitted on July 16, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #4 was admitted on May 11, 2021 and was discharged on September 10, 2021. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #5 was admitted on June 9, 2021 and was discharged on July 26, 2021. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #6 was admitted on May 26, 2021 and was discharged on January 19, 2022. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #7 was admitted on October 5, 2021 and was discharged on January 4, 2022. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
This is a repeat citation from the March 2, 2021 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
LMCMS will use an electronic signature software to capture signed acknowledgement by individuals in service that they have been notified of their client rights, including (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. These signed acknowledgements will by uploaded into their charts by 5/2/2022.
LMCMS will use the electronic signature software to capture signed acknowledgement by individuals in service that they have been notified of their rights as part of intake paperwork. This signed acknowledgement will be uploaded into individuals' charts.
Chart audits will be conducted monthly by the D&A Clinical Supervisor, to include review of signed acknowledgement by individuals in service that they have been notified of their client rights. Chart audits will involve no less that one chart reviewed per month. Issues identified through chart audits will be communicated directly with clinicians for rectification and will be used to assess for training needs. Chart audit results will be reviewed at high level on a quarterly basis to identify trends indicating programmatic level changes needed. First round of updated chart audits will be completed 4/30/2022. |
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.
|
Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that 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 in three of seven client records reviewed.
Client #1 was admitted on October 7, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #3 was admitted on July 16, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #5 was admitted on June 9, 2021 and was discharged on July 26, 2021. There was no client rights acknowledgement documented in the record at the time of the inspection.
This is a repeat citation from the March 2, 2021 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
LMCMS will use an electronic signature software to capture signed acknowledgement by individuals in service that they have been notified of their client rights, including (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. These signed acknowledgements will by uploaded into their charts by 5/2/2022.
LMCMS will use the electronic signature software to capture signed acknowledgement by individuals in service that they have been notified of their rights as part of intake paperwork. This signed acknowledgement will be uploaded into individuals' charts.
Chart audits will be conducted monthly by the D&A Clinical Supervisor, to include review of the signed acknowledgement by individuals in service that they have been notified of their client rights. Chart audits will involve no less that one chart reviewed per month. Issues identified through chart audits will be communicated directly with clinicians for rectification and will be used to assess for training needs. Chart audit results will be reviewed at high level on a quarterly basis to identify trends indicating programmatic level changes needed. First round of updated chart audits will be completed 4/30/2022. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
|
Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and that reasons for removing sections shall be documented in the record in seven of seven client records reviewed.
Client #1 was admitted on October 7, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #2 was admitted on May 19, 2021 and was still active at the time of the inspection. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #3 was admitted on July 16, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #4 was admitted on May 11, 2021 and was discharged on September 10, 2021. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #5 was admitted on June 9, 2021 and was discharged on July 26, 2021. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #6 was admitted on May 26, 2021 and was discharged on January 19, 2022. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #7 was admitted on October 5, 2021 and was discharged on January 4, 2022. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
This is a repeat citation from the March 2, 2021 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
LMCMS will use an electronic signature software to capture signed acknowledgement by individuals in service that they have been notified of their client rights, including (3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. These signed acknowledgements will by uploaded into their charts by 5/2/2022.
LMCMS will use the electronic signature software to capture signed acknowledgement by individuals in service that they have been notified of their rights as part of intake paperwork. This signed acknowledgement will be uploaded into individuals' charts.
Chart audits will be conducted monthly by the D&A Clinical Supervisor, to include review of the signed acknowledgement by individuals in service that they have been notified of their client rights. Chart audits will involve no less that one chart reviewed per month. Issues identified through chart audits will be communicated directly with clinicians for rectification and will be used to assess for training needs. Chart audit results will be reviewed at high level on a quarterly basis to identify trends indicating programmatic level changes needed. First round of updated chart audits will be completed 4/30/2022.
|
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.
|
Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in seven of seven client records reviewed.
Client #1 was admitted on October 7, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #2 was admitted on May 19, 2021 and was still active at the time of the inspection. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #3 was admitted on July 16, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #4 was admitted on May 11, 2021 and was discharged on September 10, 2021. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #5 was admitted on June 9, 2021 and was discharged on July 26, 2021. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #6 was admitted on May 26, 2021 and was discharged on January 19, 2022. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #7 was admitted on October 5, 2021 and was discharged on January 4, 2022. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
This is a repeat citation from the March 2, 2021 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
LMCMS will use an electronic signature software to capture signed acknowledgement by individuals in service that they have been notified of their client rights, including (4) Clients have the right to appeal a decision limiting access to their records to the director. These signed acknowledgements will by uploaded into their charts by 5/2/2022.
LMCMS will use the electronic signature software to capture signed acknowledgement by individuals in service that they have been notified of their rights as part of intake paperwork. This signed acknowledgement will be uploaded into individuals' charts.
Chart audits will be conducted monthly by the D&A Clinical Supervisor, to include review of the signed acknowledgement by individuals in service that they have been notified of their client rights. Chart audits will involve no less that one chart reviewed per month. Issues identified through chart audits will be communicated directly with clinicians for rectification and will be used to assess for training needs. Chart audit results will be reviewed at high level on a quarterly basis to identify trends indicating programmatic level changes needed. First round of updated chart audits will be completed 4/30/2022. |
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.
|
Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records in seven of seven client records reviewed.
Client #1 was admitted on October 7, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #2 was admitted on May 19, 2021 and was still active at the time of the inspection. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #3 was admitted on July 16, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #4 was admitted on May 11, 2021 and was discharged on September 10, 2021. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #5 was admitted on June 9, 2021 and was discharged on July 26, 2021. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #6 was admitted on May 26, 2021 and was discharged on January 19, 2022. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #7 was admitted on October 5, 2021 and was discharged on January 4, 2022. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
This is a repeat citation from the March 2, 2021 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
LMCMS will use an electronic signature software to capture signed acknowledgement by individuals in service that they have been notified of their client rights, including (5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. These signed acknowledgements will by uploaded into their charts by 5/2/2022.
LMCMS will use the electronic signature software to capture signed acknowledgement by individuals in service that they have been notified of their rights as part of intake paperwork. This signed acknowledgement will be uploaded into individuals' charts.
Chart audits will be conducted monthly by the D&A Clinical Supervisor, to include review of the signed acknowledgement by individuals in service that they have been notified of their client rights. Chart audits will involve no less that one chart reviewed per month. Issues identified through chart audits will be communicated directly with clinicians for rectification and will be used to assess for training needs. Chart audit results will be reviewed at high level on a quarterly basis to identify trends indicating programmatic level changes needed. First round of updated chart audits will be completed 4/30/2022.
|
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
|
Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in seven of seven client records reviewed.
Client #1 was admitted on October 7, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #2 was admitted on May 19, 2021 and was still active at the time of the inspection. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #3 was admitted on July 16, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #4 was admitted on May 11, 2021 and was discharged on September 10, 2021. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #5 was admitted on June 9, 2021 and was discharged on July 26, 2021. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #6 was admitted on May 26, 2021 and was discharged on January 19, 2022. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
Client #7 was admitted on October 5, 2021 and was discharged on January 4, 2022. The client rights acknowledgement form in the client record did not include notification of this regulatory client right.
This is a repeat citation from the March 2, 2021 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
LMCMS will use an electronic signature software to capture signed acknowledgement by individuals in service that they have been notified of their client rights, including (6) Clients have the right to submit rebuttal data or memoranda to their own records. These signed acknowledgements will by uploaded into their charts by 5/2/2022.
LMCMS will use the electronic signature software to capture signed acknowledgement by individuals in service that they have been notified of their rights as part of intake paperwork. This signed acknowledgement will be uploaded into individuals' charts.
Chart audits will be conducted monthly by the D&A Clinical Supervisor, to include review of the signed acknowledgement by individuals in service that they have been notified of their client rights. Chart audits will involve no less that one chart reviewed per month. Issues identified through chart audits will be communicated directly with clinicians for rectification and will be used to assess for training needs. Chart audit results will be reviewed at high level on a quarterly basis to identify trends indicating programmatic level changes needed. First round of updated chart audits will be completed 4/30/2022.
|
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
|
Observations
Based on a review of client records, the facility failed to document client orientation to the project during intake in three of seven client records reviewed.
Client #1 was admitted on October 7, 2021 and was still active at the time of the inspection. There was no client orientation documented in the record at the time of the inspection.
Client #3 was admitted on July 16, 2021 and was still active at the time of the inspection. There was no client orientation documented in the record at the time of the inspection.
Client #5 was admitted on June 9, 2021 and was discharged on July 26, 2021. There was no client orientation documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
LMCMS will use an electronic signature software to orient individuals to the project during intake and to capture signed acknowledgement that they have received and read the orientation materials, including project policies. These signed acknowledgements will by uploaded into their charts by 5/2/2022.
LMCMS will use the electronic signature software to capture signed acknowledgement by individuals in service that they received project policies as part of intake paperwork. This signed acknowledgement will be uploaded into individuals' charts.
Chart audits will be conducted monthly by the D&A Clinical Supervisor, to include review of the client orientation of the project to ensure signed acknowledgement is captured. Chart audits will involve no less that one chart reviewed per month. Issues identified through chart audits will be communicated directly with clinicians for rectification and will be used to assess for training needs. Chart audit results will be reviewed at high level on a quarterly basis to identify trends indicating programmatic level changes needed. First round of updated chart audits will be completed 4/30/2022.
|
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on a review of client records, the facility failed to document a consent to treatment during intake in three of seven client records reviewed.
Client #1 was admitted on October 7, 2021 and was still active at the time of the inspection. There was no consent to treatment documented in the record at the time of the inspection.
Client #3 was admitted on July 16, 2021 and was still active at the time of the inspection. There was no consent to treatment documented in the record at the time of the inspection.
Client #5 was admitted on June 9, 2021 and was discharged on July 26, 2021. There was no consent to treatment documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
LMCMS will use an electronic signature software to obtain signed consent to treatment. These signed consent will by uploaded into their charts by 5/2/2022.
LMCMS will use the electronic signature software to capture signed consent to treatment as part of intake paperwork. This signed consent will be uploaded into individuals' charts.
Chart audits will be conducted monthly by the D&A Clinical Supervisor, to include review of the client consent to treatment to ensure signed consent is captured. Chart audits will involve no less that one chart reviewed per month. Issues identified through chart audits will be communicated directly with clinicians for rectification and will be used to assess for training needs. Chart audit results will be reviewed at high level on a quarterly basis to identify trends indicating programmatic level changes needed. First round of updated chart audits will be completed 4/30/2022.
|
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.
|
Observations
Based on a review of client records, the facility failed to document the type and/or frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client #2 was admitted on May 19, 2021 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 28, 2021; however, the plan did not document the type and frequency of treatment and rehabilitation services.
Client #6 was admitted on May 26, 2021 and was discharged on January 19, 2022. The individual treatment and rehabilitation plan was completed on June 15, 2021; however, the plan did not document the type of treatment and rehabilitation services.
Client #7 was admitted on October 5, 2021 and was discharged on January 4, 2022. The individual treatment and rehabilitation plan was completed on October 12, 2021; however, the plan did not document the frequency of treatment and rehabilitation services.
This is a repeat citation from the March 2, 2021 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The LMCMS Outpatient Chart Audit tool will be updated by 3/18/2022 to check that D&A Treatment Plans contain type and frequency of treatment and rehabilitation services. Chart audits will be conducted monthly by the D&A Clinical Supervisor and will involve no less that one chart reviewed per month. Issues identified through chart audits will be communicated directly with clinicians for rectification and will be used to assess for training needs. Chart audit results will be reviewed at high level on a quarterly basis to identify trends indicating programmatic level changes needed. Any chart found to be out of compliance with regulations regarding the documentation of type and frequency of treatment and rehabilitation services will require the recording clinician to re-take the regulations training (outlined below), regardless of whether they have already been trained in this area.
All D&A Clinicians will be trained (or retrained, if applicable) by the D&A Clinical Director and the D&A Clinical Supervisor on how to properly document treatment and rehabilitation services, including but not limited to the necessity to document the type and frequency of treatment and rehabilitation services within the treatment plan. This training will also be required by all new clinicians (FT, IC, and Intern) and completion of this training will be tracked and monitored as per the POC items above for Citations 704.11(a)(3), 704.11(e)(1), and 704.11(d)(2). This training will be completed by 5/2/2022.
|
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.
|
Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in three of six applicable client records reviewed.
Client #1 was admitted on October 7, 2021 and was still active at the time of the inspection. The individual treatment plan was completed on October 9, 2021 and an update was due no later than December 9, 2021; however, the update was not completed until January 25, 2022.
Client #2 was admitted on May 19, 2021 and was still active at the time of the inspection. The individual treatment plan was completed on June 28, 2021 and an update was due no later than August 28, 2021; however, the update was not completed until September 24, 2021. Additionally, a treatment plan update was completed on October 7, 2021 and another update was due no later than December 7, 2021; however, the update was not completed at the time of the inspection.
Client #6 was admitted on May 26, 2021 and was discharged on January 19, 2022. A treatment plan update was completed on August 16, 2021 and another update was due no later than October 16, 2021; however, the update was not completed prior to discharge.
This is a repeat citation from the March 2, 2021 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The D&A Clinical Supervisor will bi-weekly pull a report of treatment plans that are coming due over the course of 30 days and send D&A Clinicians the data for their caseloads. QA Manager will train D&A Clinical Supervisor in how to pull, reformat, and distribute the reports and the new process will commence by 5/2/2022.
Client #2 has not engaged in services since November '21 and a treatment plan cannot be completed. Client #2 will be discharged from the program by 3/18/2022.
Chart audits will be conducted monthly by the D&A Clinical Supervisor to include review of treatment and rehabilitation plan completion timeliness. Chart audits will involve no less that one chart reviewed per month. First round of updated chart audits will be completed 4/30/2022. Issues identified through chart audits will be communicated directly with clinicians for rectification and will be used to assess for training needs. Chart audit results will be reviewed at high level on a quarterly basis to identify trends indicating programmatic level changes needed.
|
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.
|
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 five of five applicable client records reviewed.
Client #1 was admitted on October 7, 2021 and was still active at the time of the inspection. The record did not document any case consultation notes at the time of the inspection.
Client #2 was admitted on May 19, 2021 and was still active at the time of the inspection. The record did not document any case consultation notes at the time of the inspection.
Client #3 was admitted on July 16, 2021 and was still active at the time of the inspection. The record did not document any case consultation notes at the time of the inspection.
Client #4 was admitted on May 11, 2021 and was discharged on September 10, 2021. The record did not document any case consultation notes at the time of the inspection.
Client #6 was admitted on May 26, 2021 and was discharged on January 19, 2022. The record did not document any case consultation notes at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
LMCMS will utilize standardized case consultation forms. D&A Clinicians will be trained on how to complete the case consultation form and the regulations regarding use of said form by the D&A Clinical Director and the D&A Clinical Supervisor by 5/2/2022. Training on this topic will be tracked as outlined above for Citations 704.11(a)(3), 704.11(e)(1), and 704.11(d)(2).
A case consultation note for Client #1 will be completed by the attending practitioner and uploaded to the client's chart by 3/18/2022.
A case consultation note for Client #2 will not be completed because the client in not engaged with services and will be discharged by 3/18/2022.
A case consultation note for Client #3 will be completed by the attending practitioner and uploaded to the client's chart by 3/18/2022.
The LMCMS Outpatient Chart Audit tool will be updated by 3/18/2022 to check that case consultation forms have been completed and uploaded into charts as applicable. Chart audits will be conducted monthly by the D&A Clinical Supervisor and will involve no less that one chart reviewed per month. Issues identified through chart audits will be communicated directly with clinicians for rectification and will be used to assess for training needs. Chart audit results will be reviewed at high level on a quarterly basis to identify trends indicating programmatic level changes needed. First round of updated chart audits will be completed 4/30/2022.
|
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.
|
Observations
Based on a review of client records, the facility failed to document follow-up information in three of four applicable client records reviewed.
Client #4 was admitted on May 11, 2021 and was discharged on September 10, 2021. The client record did not document follow-up information as of the date of the inspection.
Client #6 was admitted on May 26, 2021 and was discharged on January 19, 2022. The client record did not document follow-up information as of the date of the inspection.
Client #7 was admitted on October 5, 2021 and was discharged on January 4, 2022. The client record did not document follow-up information as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
D&A Clinical Director will train the D&A Clinical Supervisor on how to complete follow-up for discharged individuals and on the regulations regarding follow-up and missing follow-up will be conducted by the D&A Clinical Supervisor as follows:
Follow-up for Client #4 will be completed by the D&C Clinical Supervisor by 3/18/2022 and uploaded into the client's chart.
Follow-up for Client #6 will be completed by the D&C Clinical Supervisor by 3/18/2022 and uploaded into the client's chart.
Follow-up for Client #7 will be completed by the D&C Clinical Supervisor by 3/18/2022 and uploaded into the client's chart.
Chart audits will be conducted monthly by the D&A Clinical Supervisor to include review of completed follow-up forms for discharged individuals. Chart audits will involve no less that one chart reviewed per month. Issues identified through chart audits will be communicated directly with clinicians for rectification and will be used to assess for training needs. Chart audit results will be reviewed at high level on a quarterly basis to identify trends indicating programmatic level changes needed. First round of updated chart audits will be completed 4/30/2022.
|