INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 13, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Public Health Management Corporation d/b/a Chances 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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704.11(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.
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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 records reviewed.
Employee # 2 was hired as a counselor on April 29, 2019. The personnel record documented 8 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will monitor the training record for staff on a monthly basis. The training records will be reviewed in supervision to ensure that adherence to the training timeline is completed. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's September 2020 through December 2021 fire drill log, the facility failed to ensure that their written fire drill log for November 2021 included the number of persons in the facility at the time of the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will train all staff on the correct manner to complete the fire drill logs. This training will take place on March 2, 2022 during the all staff meeting.
The fire drill logs will be reviewed by the Program Director on a monthly basis to ensure that the logs are completed properly.
The fire drill logs will also be reviewed by the quality management team on a quarterly basis starting April 15th, 2022. |
709.24 (a) (3) 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:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in three of seven records reviewed.
The facility's policy and procedure manual stated that the comprehensive treatment plan is to be completed within 30 days of the admission date. Additionally, the manual stated that the psychosocial evaluation is to be completed within 30 days of admission.
Client # 1 was admitted on August 16, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than September 18, 2021; however, the treatment plan was not completed until November 15, 2021. Additionally, the psychosocial evaluation was due to be completed no later than September 18, 2021; however, the evaluation was not completed until November 11, 2021.
Client # 2 was admitted on September 14, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than October 14, 2021; however, the treatment plan was not completed until October 22, 2021.
Client # 3 was admitted on September 1, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than October 1, 2021; however, the treatment plan was not completed until January 12, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will complete a training for all staff on the proper timeline for completion of the treatment plans. The training will occur on March 4, 2022.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2022
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency or organization to whom disclosure is made to on consent to release information forms in seven of seven client records reviewed.
Each client record reviewed contained two blank release of information forms that failed to document the specific name of the person, agency or organization to whom disclosure would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will complete a training for all staff on the correct manner to complete the release of information. The training will occur on March 4, 2022.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2022
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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.
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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, 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.
In every client record reviewed, the client rights acknowledgement form did not include notification of this particular regulatory client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Compliance team will update the bill of rights form provided to the participants at intake to include this information. The completed form will be implemented on February 28, 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.
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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 of their right to appeal a decision limiting access to their records to the director in seven of seven client records reviewed.
In every client record reviewed, the client rights acknowledgement form did not include notification of this particular regulatory client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Compliance team will update the bill of rights form provided to the participants at intake to include this information. The completed form will be implemented on February 28, 2022.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2022
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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 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.
In every client record reviewed, the client rights acknowledgement form did not include notification of this particular regulatory client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Compliance team will update the bill of rights form provided to the participants at intake to include this information. The completed form will be implemented on February 28, 2022.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2022
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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.
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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 of their right to submit rebuttal data or memoranda to their own records in seven of seven client records reviewed.
In every client record reviewed, the client rights acknowledgement form did not include notification of this particular regulatory client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Compliance team will update the bill of rights form provided to the participants at intake to include this information. The completed form will be implemented on February 28, 2022.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2022
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake process, a psychosocial evaluation of the client in six of seven client records reviewed.
Client # 2 was admitted on September 14, 2021 and was still active at the time of the inspection.
The client record did not include documentation of a psychosocial evaluation at the time of the inspection.
Client # 3 was admitted on September 1, 2021 and was still active at the time of the inspection. The client record did not include documentation of a psychosocial evaluation at the time of the inspection.
Client # 4 was admitted on August 24, 2021 and was discharged on October 15, 2021. The client record did not include documentation of a psychosocial evaluation at the time of the inspection.
Client # 5 was admitted on August 16, 2021 and was discharged on October 1, 2021. The client record did not include documentation of a psychosocial evaluation at the time of the inspection.
Client # 6 was admitted on August 27, 2021 and was discharged on December 14, 2021. The client record did not include documentation of a psychosocial evaluation at the time of the inspection.
Client # 7 was admitted on July 12, 2021 and was discharged on November 24, 2021. The client record did not include documentation of a psychosocial evaluation 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 Program Director will complete a training for all staff on the proper timeline for completion of the psychosocial evaluation. The training will occur on March 4, 2022.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2022
The missing psychosocial evaluation documentation for any active clients listed will be included in the chart by 4/15/2022. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan, developed with the client, in four of seven client records reviewed.
Client # 4 was admitted on August 24, 2021 and was discharged on October 15, 2021. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client # 5 was admitted on August 16, 2021 and was discharged on October 1, 2021. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client # 6 was admitted on August 27, 2021 and was discharged on December 14, 2021. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client # 7 was admitted on July 12, 2021 and was discharged on November 24, 2021. There was no individual treatment and rehabilitation plan documented in the client record 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 Program Director will complete a training for all staff on the proper timeline for completion of the treatment plans. The training will occur on March 4, 2022.
Compliance to the standard will also be monitored by Total Quality Management which reviews charts on a quarterly basis.
First quarterly review will take place by 4/15/2022
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