INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 22-23, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Angel's Light Addiction Specialists 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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709.24 (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 administrative information, the facility failed to include a case consultation in the written procedures for the management of treatment and rehabilitation services for clients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The organization's management added to the policy and procedure manual case consultation as a written procedure for the management of treatment and rehabilitation for clients.
Policy # 40 of the organization's policy and procedure manual states:
"Case Consultation of each client status in treatment is completed and entered in the client's medical record one time during client's course of treatment at the 15 day mark since client's admission to the program"
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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.
Client records #3 and #4 contained documentation that information was released without documentation of a signed release of information.
Client #3 was admitted on September 26, 2020 and is still an active client. There was a correspondence letter written to "All interested parties" documented in client record #3. It is unknown who the "All interested parties" was and if there was a signed consent to release the information. In addition, there was a thirty page fax sent to another service provider. There was no signed release of information for the service provider.
Client #4 was admitted on August 27, 2020 and discharged on October 1, 2020. On September 23, 2020 there was a note stating that a funding source was contacted for transfer, but there was no signed release of information documented for the funding source. On September 8, 2020, there was a fax sent to a third party, yet there was no signed release of information signed for this third party. On September 24, 2020, there was another fax sent to another outside agency, with no signed release on information documented. Lastly, there was a twenty seven page fax sent to another treatment provider with no signed release of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/24/2020, the organization scheduled to conduct all staff members training on "Confidentiality of drug and alcohol patient information, 42 CFR Part 2".
All staff members will sign in for the training.
All staff members will receive a copy of the organization policy on "Confidentiality of of drug and alcohol patient information" and a picture of General rule of confidentiality and exceptions permitted for disclosure."
Clinical Supervisor ongoing chart reviews and will share findings with clinicians.
If any errors found in this area, Clinical Supervisor will address them with the counselor who is responsible for the client and medical record.
Training will be provided again, along with steps of the disciplinary process.
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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.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on all of the signed releases of information contained in client records #1, #6 and #7.
Client record #1 contained signed releases of information dated October 2, 2020, that did not include the purpose of disclosure.
Client record #6 contained signed releases of information dated June 13, 2020, that did not include the purpose of disclosure.
Client record #7 contained signed releases of information dated May 29, 2020, that did not include the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The organization updated clinical forms, including Release of Information to include purpose of disclosure.
All staff members received the new and updated Release of Information form to be used for medical records starting 11/2/2020.
Clinical Supervisor conducts ongoing chart reviews and shares findings with clinicians.
Clinical Supervisor has been doing some of the filling in an effort to look at each form who enters the medical record. |
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.
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Observations
Based on a review of facility policies, the facility failed to document written policies on client rights which included 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. No client may be deprived of a civil right solely by reason of treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The organization management added to the policy and procedure manual and clients rights form the following rights:
"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. "
This change occurred as of 11/2/2020. |
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 facility policy, the facility failed to document a client rights policy which included that - Clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The organization updated the policy and procedure manual "Clients Rights" policy and "Clients Rights" form to include:
"Clients have the right to submit rebuttal data or memoranda to their own records."
This change occurred as of 11/2/2020.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document that counseling services were provided as per the treatment plan.
All of the treatment plans reviewed stated that clients are to receive individual therapy weekly and group therapy daily.
Client #2 was admitted on September 23, 2020 and is still an active client. There were no therapy services documented form October 16-19, 2020 and 10/21/2020. There were no individual sessions documented since October 8, 2020.
Client #3 was admitted on September 26, 2020 and is still an active client. The last therapy entry on the record of service was an individual session on October 11, 2020; however, there was no corresponding progress note.
Client #4 was admitted on August 27, 2020 and discharged on October 1, 2020. There were no individual sessions documented from September 21 - October 1, 2020.
Client #7 was admitted on May 29, 2020 and discharged on July 6, 2020. There were no individual sessions documented from June 19, 2020 - July 6, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinicians received training on the services and the frequency of services that must be provided to clients according to each client individualized treatment plan.
Staff was reminded that the documentation must be recorded within the 24 hours since the service was provided.
Clinical Supervisor performs weekly reviews of the medical records to ensure such services are provided and documented.
Change occurred as of 11/2/2020. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete record of services provided in four of seven client records.
Client #2 was admitted on September 23, 2020 and is still an active client. Client #2's record of service was blank from October 16 - October 19 and October 21. There was no individual therapy sessions documented since October 8, 2020.
Client #3 was admitted on September 26, 2020 and is still an active client. The last therapy session documented on the record of service was dated October 11, 2020. The last supportive service documented on the record of service was October 17, 2020. The record of service was blank after October 17, 2020. There were progress notes dated 10/19, 10/17, 10/15, 10/14, and 10/11/2020 that had no services documented on the record of service.
Client #4 was admitted on August 27, 2020 and discharged on October 1, 2020. There was a progress note for an individual session dated September 10, 2020 that was not on the record of service. There were no individual sessions documented on the record of service from September 21 - October 1, 2020.
Client #7 was admitted on May 29, 2020 and discharged on July 6, 2020. There were no individual session documented on the record of service from June 19 - July 6, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff members have been trained of completing the record of services provided to each client.
All services provided to client as part of their treatment need to match the record of services form.
Clinical Supervisor completes weekly charts review to ensure this task is completed.
This change occurred as of 11/9/2020. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in two of four client records.
Client #4 was admitted on August 27, 2020 and discharged on October 1, 2020. There was no discharge summary in client record #4.
Client #7 was admitted on May 29, 2020 and discharged on July 6, 2020. There was no discharge summary in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors have been trained on completion of discharge summary and post discharge follow up according to the timelines established in the policy and procedure manual (within five business days of client's discharge from the program).
This changed occurred as of 11/9/2020.
Clinical Supervisor conducts ongoing chart reviews and will review findings with clinicians.
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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 client records #4 and #5. The facility policy states that follow up will occur within 7 days of discharge.
Client #4 was admitted on August 27, 2020 and discharged on October 1, 2020. There was no follow up in client record #4.
Client #5 was admitted on June 25, 2020 and discharged on August 6, 2020. There was no follow up in client record #5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The organization policy and procedure manual was updated to include that post discharge follow up is to occur within 48 hours for clients who discharge AMA or administratively, and within five business days for regular discharges.
All staff members have been trained on this procedure as of 11/9/2020.
Clinical Supervisor conducts weekly charts review to ensure this procedure is completed as according to the timelines established in the organization's policy manual. |