INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Laure Rohrs Gargano 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 client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for not following their policy on when discharge summaries are completed in one out of three applicable records reviewed. The facility ' s policy and procedures manual stated that discharge summaries are completed within seven days. Additionally, the facility failed to follow their policy on when follow up contact is completed in three out of three applicable records reviewed. The facility ' s policy and procedures manual states that follow up contacts are completed at 15, 30 and 60 days after a successful discharge.
Client #5 was admitted on November 27, 2023 and discharged on February 7, 2024. A discharge summary was due no later than February 14, 2024; however, it was not completed until March 23, 2024. A follow up contact was due no later than April 7, 2024; however, it was not completed until April 8, 2024.
Client #6 was admitted on May 16, 2023 and discharged on December 19, 2023. A follow up was due no later than January 3, 2024, January 19, 2024 and February 19, 2024; however there was only one completed on January 30, 2024.
Client #7 was admitted on July 12, 2022 and discharged on May 14, 2024. A follow up contact was due no later than May 29, 2024, June 14, 2024 and July 14, 2024; however, there is no documentation that follow up contacts occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will make a policy change to the timeframes for the discharge summary and follow up contact schedule.
Discharge summaries are to be completed within 30 days post discharge.
Follow up contacts will occur: 15 days post discharge for non-routine discharges. A follow up contact will occur within 30 days of discharge for routine/treatment complete status.
The program director will be responsible for the follow up out reaches at or before the identified timeframe. The follow up contact will be noted in the electronic chart under "contact"
The program director will complete chart audits 30 days post discharge to ensure compliance with agency policy. |
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 out of seven records reviewed.
Client #2 was admitted on August 22, 2023 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for a family member; however, the facility had documented in the client record a telephone call with the family member on February 21, 2024.
This is a repeat citation from the June 9, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will create an electronic ROI to be completed at the time of intake. THe primary counselor will discuss with client who needs to be involved in their treatment; secure name, address and phone number to complete the ROI with the client. Client will sign the ROI through the electronic record; it will automatically upload to their file.
For client whom are telehealth one of two options my utilized:
The electronic ROI will be sent through the electronic record; Client will then be responsible to complete the required information, sign and it will auto upload to file. Counselor will review for accuracy and compliance with required information.
Option 2:
The counselor will complete a separate electronic ROI, the Counselor will enter required information; forward to client via email for electronic signature; after client reviews signs and initials; the counselor will then electronically sign; the PDF ROI will be scanned and uploaded to client file.
The program director will complete chart month end audits to ensure compliance with agency policy. When/if deficiency is found, the primary counseling will be informed, and secure the needed ROI. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of seven client records reviewed.
Client #2 was admitted on August 22, 2023 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a mental health provider and a legal entity dated February 26, 2024, were offered to the client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will add a required electronic entry to ROI's in the client portal for client to initial
acknowledgement that the client is aware they are entitled to copies of the ROI's and any other intake paperwork.
The Program director will ensure that addition of required initials indicated clients right to a copy of paperwork is added to each form. The Program director will review new admissions with 10 days of admission to ensure the plan of correction has been implemented correctly.
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment and rehabilitation plans in five out of five applicable records reviewed.
Client #1 was admitted on November 14, 2023 and was still active at the time of the inspection. The comprehensive treatment plan that was completed on November 15, 2023 did not have documentation of support services.
Client #2 was admitted on August 22, 2023 and was still active at the time of the inspection. The comprehensive treatment plan that was completed on August 29, 2023 did not have documentation of support services.
Client #3 was admitted on January 2, 2024 and was still active at the time of the inspection. The comprehensive treatment plan that was completed on January 15, 2024 did not have documentation of support services.
Client #4 was admitted on November 2, 2023 and still active at the time of the inspection. The comprehensive treatment plan that was completed on December 7, 2023 did not have documentation of support services.
Client #5 was admitted on November 27, 2023 and discharged on February 7, 2024. The comprehensive treatment plan that was completed on December 6, 2023 did not have documentation of support services.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program director will re-educate primary counselors about the requirement to include support services being included in the master treatment plan, and subsequent updates. This will be completed in a team meeting for all primary therapist.
The program director will complete monthly chart audits the treatment plans include identification of support services on master treatment plans; and treatment plan updates. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan in one out of three applicable records. The facility's policy and procedures manual states that an aftercare plan is completed by the last session for a successful discharge.
Client #7 was admitted on July 12, 2022 and was successfully discharged on May 14, 2024. An aftercare plan was due no later than May 14, 2024; however, there is no documentation that one was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will create an electronic Aftercare form to be completed and auto uploaded to client file. This form can be completed either in person or virtually.
Program Director will monitor compliance with chart audits for 90 days to ensure compliance. |