Agape Community Integrated Health Systems Investigation

PRINTED: 12/07/2018
FORM APPROVED
StateofGA,HealthcareFacilityRegulationDivision
STATEMENTOFDEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA( X2)MULTIPLECONSTRUCTION( X3)DATESURVEY
ANDPLANOFCORRECTION IDENTIFICATIONNUMBER: A.BUILDING: COMPLETED
060- B.WING _____________________________

435- D10/ 18/ 2018
NAMEOFPROVIDERORSUPPLIERSTREET ADDRESS,CITY,STATE, ZIPCODE
2001MARTIN LUTHER KINGDRIVE, SUITE420
AGAPECOMMUNITY INTEGRATED HEALTH SYSTEMS
ATLANTA, GA 30310
IDID(
X4) SUMMARYSTATEMENTOFDEFICIENCIESPROVIDER'SPLANOFCORRECTION X5)
EACHDEFICIENCYMUSTBEPRECEDEDBYFULL (
PREFIXPREFIX EACHCORRECTIVEACTIONSHOULDBE COMPLETE
REGULATORYORLSCIDENTIFYINGINFORMATION)
TAGTAG CROSS-REFERENCEDTOTHEAPPROPRIATE DATE
DEFICIENCY)
N000Initial Comments. N000
Thepurposeofthisvisitwastoconducta
complianceinspection. Thefollowingrulesor
regulatoryviolationcited:
N928111-8-19-.09(7)Administration. N928
SS=D
PersonnelRecords.Aprogramshallmaintain
writtenrecordsforeachemployeeandthe
administrator.Eachindividualfileshallinclude:
a) Identifyinginformationsuchasname,
address,telephonenumber,emergencycontact
person(s);
b) Atenyearemploymenthistoryoracomplete
employmenthistoryifthepersonhasnotworked
tenyears;
c) Recordsofapplicablelicenses,health
requirements,andeducationalqualificationsas
requiredbytheserules;
d) Dateofemployment;
e) Theperson'sjobdescriptionorstatementsof
theperson'sdutiesandresponsibilities;
f) Documentationoftrainingandorientation
requiredbytheserules;
g) Anyrecordsrelevanttotheemployee's
performanceincludingatleastannual
performanceevaluations; and
h) Theresultsofemploymentandcriminal
backgroundchecksconductedbytheprogram
priortoemploymentindicatingthattheemployee
hasnohistoryofviolenceorabusewhichwould
posearisktoclientsreceivingservicesthrough
thetreatmentprogram.
ThisRULE isnotmetasevidencedby:
Basedonrecordreviewandstaffinterview,
thefacilityfailedtomaintaincompleteemployee
State of GA Inspection Report
LABORATORYDIRECTOR'SORPROVIDER/SUPPLIERREPRESENTATIVE'SSIGNATURETITLE( X6) DATE
STATE FORM 6899

MYIU11 Ifcontinuationsheet 1of17
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IDID(
DEFICIENCY)
N928Continued From page 1 N928

files. Findingsinclude:
ThefilesforstaffA,B,C,D,E,F,G,H,andIdid
notcontaindocumentationthatthefacility
maintaincompleteemployeefiles.
Thefilesforstaff A,B,C,D,E,F,G,H,andIdid
notdocumentationacriminalbackgroundcheck
atthetimeofhire.
ThefilesforstaffA,C,D,E,F,G,andIdidnot
containdocumentationapre-employeedrug
screenatthetimeofhire.
ThefileforstaffA,B,C,D,E,G,H,andIdidnot
containdocumentationthefacilitycompleted
ongoingrandomdrugscreens.
ThefilesforstaffA,C,andDdidnotcontain
documentationthestaffhadcurrentlicenses.
ThefilesforstaffB,C,D,E,F,G,andHdidnot
containdocumentationthereferenceswere
checkedatthetimeofhire.
ThefilesforstaffA,B,C,D,E,G,H,andIdidnot
containdocumentationthatthefacilitycompleted
stafforientationpriortoworkingwithclients.
ThestafffiledforstaffA,E,G,H,andIdidnot
containdocumentationannualperformance
evaluationwereconducted.
Thefilesforstaff A,C,E,F,G,andIdidnot
containdocumentationthestaffreceived30clock
hoursoftrainigyearly
Inaninterviewon10/18/18at2:00p.m.staffH
statedthemissingdocumentscouldnotbe
STATE FORM 6899
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435- D10/ 18/ 2018
ATLANTA, GA 30310
IDID(
DEFICIENCY)

produced.
SS=D
EmergencyServices. Duringnon-operatinghours,
theprogrammustmakeprovisionsfor24hour
emergencyservicesoratelephone "hotline"to
assistaclientinacrisissituation.Thisinformation
mustbeprovidedtotheclientuponadmission.
Basedonareviewoffacilityrecordsand
staffinterview,thefacilityfailedtomakeprovisions
for24houremergencyservicesduring
non-operatinghours. Findingsinclude:
Areviewofthefacilitypolicesandproceduresdid
notshowdocumentationofpoliciesand
proceduresforemergencyservicesduring
non-operatinghours.
Inaninterviewon10/18/18at11:00a.m.,staffH
statedthatmissingdocumentationcouldnotbe
produced.
SS=D
Drug-freeworkplace.Writtenpoliciesand
proceduresshallbeestablishedandimplemented
toprovideforadrug-freeworkplace.
Pre-employmentandongoingrandomurinedrug
screensshallbeutilizedforallprogram
employees.Eachsamplecollectedshallbe
screenedforopiates,methadone,amphetamines,
cocaine,benzodiazepines,THCandotherdrugs
eitherasindicatedbythedepartmentorthe
employer.
STATE FORM 6899
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435- D10/ 18/ 2018
ATLANTA, GA 30310
IDID(
DEFICIENCY)
Basedonrecordsreviewandstaffinterview,
thefacilityfailedtohavepoliciesandprocedures
foradrug-freeworkplace. Whichincludes
pre-employmentandongoingrandomurinedrug
screenswhichscreenedfor opiates,methadone,
amphetamines,cocaine,Benzodiazepines, THC
andotherdrugseitherasindicatedbythe
departmentortheemployer. Findingsinclude:
Areviewofthefacilitypoliciesandproceduresdid
nothavedocumentationofpoliciesand
proceduresforadrug-freeworkplace.
ThefilesforstaffA,C,D,E,F,G,andIdidnot
containdocumentationapre-employmentdrug
screenatthetimeofhire.
ThefilesforstaffA,B,C,D,,E,G,H,andIdidnot
Inaninterviewon10/18/18at2:00p.m.,staff H
produced.
SS=D
ReferraltoOtherPrograms.Eachprogramshall
haveaformalplanofcooperationwithother
programsinthestateforreferralofclientstoallow
forcontinuityofcarefordrugdependentpersons
orforemergencyhospitalization.Thelicensed
programsmusthaveidentifiedresourcesthat
wouldbeavailabletocontinuethedrug
dependentperson'scareandtohaveworkedout
STATE FORM 6899
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IDID(
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referral/transferarrangementswhereappropriate.
Basedonareviewoffacilityrecordsand
staffinterview,thefacilityfailedtohaveaformal
planofcooperationwithotherprogramsinthe
stateforreferralofclientstoallowforcontinuityof
carefordrugdependentpersonsorforemergency
hospitalization. Findingsinclude:
Areviewofthefacilityrecords,revealedthatthe
facilitydidnothaveaformalplanofcooperation
withotherprogramsinthestatesforreferralof
clients.
produced.
N1006111- 8-19-.10(7)Staffing. N1006

SS=D
Foranyemployeehiredaftertheeffectivedateof
theserules,employmentandcriminalbackground
checksshallbeconductedpriortoemployment,
andonlypersonswithnohistoryofviolenceor
abusewhichwouldposearisktotheclientsin
treatmentshallbeemployedbytheprogram.
Basedonemployeerecordreviewandstaff
interview,thefacilityfailedtoconductcriminal
backgroundcheckspriortoemployment.
Findingsinclude:
ReviewofemployeerecordsrevealedthatStaffA,
B,D,E,F,G,H,andIdidnothave
STATE FORM 6899
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IDID(
DEFICIENCY)

documentationthatthefacilityconductedcriminal
backgroundcheckspriortoemployment.
1.StaffAwashiredon12/1/14andthecriminal
backgroundcheckwasdated11/17/16.
2.StaffBwashiredon6/11/18andthecriminal
backgroundcheckwasdated6/19/18
3.StaffCwashiredon12/1/15andthecriminal
4.StaffDwashiredon9/10/18andnocriminal
backgroundcheckwascompleted.
5.StaffEwashired8/29/16andnocriminal
6.StaffFwashired5/27/15andthecriminal
7.StaffGwashired9/18/17andnocriminal
8.StaffHwashired5/15/17andnocriminal
9.StaffIwashired1/8/15andthecriminal
Inaninterviewon10/18/18at2:00p.m.,staffH
produced.
N1008111- 8-19-.10(8)(
a)Staffing. N1008
SS=D
Orientationshallincludeinstructionin:
1. Theprogram'swrittenpoliciesandprocedures
regardingitsprogrampurposeanddescription;
clientrights,responsibilities,andcomplaints;
confidentiality;andotherpoliciesandprocedures
thatarerelevanttotheemployee'srangeofduties
andresponsibilities,includingtheuseofuniversal
precautionsforinfectioncontrol,useofbehavior
managementandemergencysafetyinterventions,
andinformationaboutHIV/AIDS;
STATE FORM 6899
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IDID(
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2. Theemployee'sassigneddutiesand
responsibilities; and
3. Reportingclientprogressandproblemsto
supervisorypersonnelandproceduresfor
handlingmedicalemergenciesorotherincidents
thataffectthedeliveryoftreatmentorservices.
forstafforientationandprovidestafforientation
priortoworkingwithclientswhichincluded:1.
Theprogram'swrittenpoliciesandprocedures
regardingitsprogrampurposeanddescription;
clientrights,responsibilities,andcomplaints;
confidentiality;andotherpoliciesandprocedures
thatarerelevanttotheemployee'srangeofduties
andresponsibilities,includingtheuseofuniversal
precautionsforinfectioncontrol,useofbehavior
managementandemergencysafetyinterventions,
andinformationaboutHIV/AIDS; 2. The
employee'sassigneddutiesandresponsibilities;
and 3. Reportingclientprogressandproblemsto
supervisorypersonnelandproceduresfor
handlingmedicalemergenciesorotherincidents
thataffectthedeliveryoftreatmentorservices.
Findingsincludes:
Areviewofthefacilitypoliciesandproceduresdid
notshowdocumentationofpoliciesand
proceduresforstafforientation.
ThefilesforstaffA,B,C,D,E,G,H,andIdidnot
stafforientationpriortoworkingwithclients.
STATE FORM 6899
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IDID(
DEFICIENCY)

produced.
N1011111- 8-19-.10(8)(
b)Staffing. N1011
SS=D
Additionaltrainingconsistingofaminimumof
thirty (30)clockhoursoftrainingorinstruction
shallbeprovidedannuallyforeachstaffmember
whoprovidestreatmentservicestoclients.Such
trainingshallbeinsubjectsthatrelatetothe
employee'sassigneddutiesandresponsibilities.
Authority: O.C.G.A. §§ 26-5-5,26-5-6.
thefacilityfailedtoprovideadditionaltraining
consistingofaminimumofthirty (30)clockhours
oftrainingorinstructionannuallyforeachstaff
memberwhoprovidestreatmentservicesto
clients. Findingsinclude:
ThefilesforstaffA,C,E,F,G,andIdidnot
containdocumentationthestaffreceived30clock
hoursoftrainigyearly
produced.
N1103111- 8-19-.11(3)PhysicalPlant &Safety. N1103

SS=D
Aprogramshallhaveappropriateandsufficient
spacetomeettheprogrammaticneedsofits
clients,andcarryouttheprogram's arrayof
services.Suchspaceshallincludeareas
conducivetoprivacyforcounselingandgroup
activities,reception/waitingareas,andbathrooms
whichassureprivacyforcollectionofurine
specimens.
STATE FORM 6899
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435- D10/ 18/ 2018
ATLANTA, GA 30310
IDID(
DEFICIENCY)
Basedontouroffacilityandemployee
interview,thefacilityfailedtohaveofficespace
conducivetoprivacyforcounselingandmedical
visits.
Findingsinclude:
Atouroffacilityon10/18/18revealedthatthe
facilitydidnothavespaceforprivacyforindividual
andgroupcounseling,medicalvisits.
Inaninterviewon10/18/18at3:00p.m.,StaffH
statedthefacilityhadroomsonanotherfloorbut,
losstheleaseforthem.
N1302111- 8-19-.13(1)(
b)ClientReferral,Intake,Assess, N1302
SS=D Adm.
Writtenpoliciesandproceduresforclientreferral,
intake,assessment,andadmissionshallbe
establishedandimplementedandshallinclude
thefollowing:
b) Assessment.Allclientsadmittedtothe
programshallbeevaluatedbyastaffpersonwho
hasbeendeterminedtobequalifiedbyeducation,
training,andexperienceandwhoare
licensed/certifiedifrequiredbystatepracticeacts
toperformorcoordinatetheprovisionofsuch
assessments.Suchevaluationsshallincludea
comprehensiveassessmentoftheclient's
physical,emotional,behavioral,social,
recreational,andeducationalstatusandneeds.
Theprogramhasthediscretiontousecurrent
clinicalinformationconcerningatransitioning
clientfromanotherlicensedprogram,licensed
STATE FORM 6899
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IDID(
DEFICIENCY)

hospital,orastateorfederalagency,iftherehas
notbeenadiscontinuanceintreatment.
forclientreferral,intake,assessment,and
admission. Findingsinclude:
Areviewoffacilitypoliciesandproceduresdidnot
showdocumentationofpoliciesandprocedures
forclientreferral,intake,assessment,and
admission.
Inaninterviewon10/18/18at11;00a.m.staffH
produced.
N1303111- 8-19-.13(1)(
b)1.ClientReferral,Intake, N1303
SS=D Assess,Adm.
PhysicalAssessment.Atthetimeofadmission, a
preliminaryphysicalassessmentshallbedone,at
aminimum,byaRegisteredNurseorLicensed
PracticalNurseunderthesupervisionofaRNor
physicianandshallincludedocumentationofvital
signs,appropriatescreeningtestsforSTDand
TB,urinedrugscreens,adeterminationof
whethertheclientrequiresaphysicalor
psychiatricexaminationbyaphysicianaccording
toestablishedprotocols,andlaboratorytestsas
clinicallyindicated.Laboratorytestsrequiredupon
admissionforclientsineachprogrammodality, in
additiontothosetestsrequiredforallmodalities,
willbedeterminedbytheprogramsand
documentedintheirpolicyandproceduresasto
thecriteriausedtodetermineandspecifywhich
STATE FORM 6899
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435- D10/ 18/ 2018
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IDID(
DEFICIENCY)

minimumlabtestsaretobedoneforeach
modality.Otherlabtestsmayberequiredbythe
physicianasclinicallyindicated.Ifanexamination
byaphysicianisindicated,arrangementsshallbe
madeforsuchanexaminationasappropriate. The
assessmentshallalsoincludecircumstances
leadingtoadmission,mentalstatus,support
system,psychiatricandmedicalhistory,risk
assessmentforHIV,historyofuseofdrugs,
includingtheageofonset,duration,patterns,and
consequencesofuse,familyhistoryofdruguse,
routeofadministrationandprevioustreatment. If
aclienthasbeenreferredfortreatmentfrom
anotherfacility,theresultsofaphysical
examinationandlaboratorytestsfromtheother
facilitymaybedocumentedandusedtoassess
physicalstatus,providedthatsuchphysical
examinationwasdonewithinsixmonthsof
admission,andtherehasbeennosignificant
changeinthephysicalstatusoftheclient.Further
assessmentsorlaboratorytestsmayberequired
dependinguponthemodalityoftreatmentneeded
ortheclient'schangingcondition.
thefacilityfailedtoconductapreliminaryphysical
assessment,screenforSTD/RPRandTB,and
conductaurinedrugscreenatthetimeof
admission. Findingsinclude:
1. Thefilesforclient #1-#
4showedno
documentationofapreliminaryphysical
assessmentatthetimeofadmission.
2. Thefilesofclient #1-#
4showedno
documentationofshowednodocumentationofTB
screentestattimeofadmission.
STATE FORM 6899
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IDID(
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3. Thefilesofclient #1-#
4showedno
documentationof STD/RPRscreentestattimeof
admission.
4.Thefilesofclient #1-#
4showedno
documentationofaurinedrugscreenattimeof
admission.
5. Thefilesof #1-#
4showednodocumentationof
statedmissingdocumentscouldnotbeproduced.
N1304111- 8-19-.13(1)(
b)2.ClientReferral,Intake, N1304
SS=D Assess,Adm.
Psycho-socialassessment.Atthetimeof
admissionorassoonasclinicallyappropriate (but
nolongerthantenworkingdays),a
comprehensivepsycho-socialassessmentshall
bedoneandshalldocumentpersonalandsocial
history,includingcurrentrelationships,
educationalstatus,livingarrangements,social
habits,employmentstatus,legalstatusand
relatedareas.
Basedonareviewofclientrecordsandstaff
interview,thefacilityfailedtocompletea
psycho-socialassessmentatthetimeof
admissionorassoonasclinicallyappropriate (but
nolongerthentenworkingdays) Fiindings
include:
Areviewofclientrecordsrevealedthatclient
STATE FORM 6899
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IDID(
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1-#4,didnothaveapsycho-socialassessment
atthetimeofadmissiondocumentedinfile.
Client #1wasadmitted2/3/14andthe
psycho-socialassessmentwascompletedon
5/27/14.
Client #2wasadmitted2/9/18showedno
documentationofapsycho-socialassessmentin
thefile.
Client #3wasadmitted5/10/14andthe
psycho-socialassessmentwascompletedon
5/1/15.
Client #4wasadmitted3/3/17showedno
documentationofapsycho-socialassessmentin
thefile.
produced.
N1311111- 8-19-.13(1)(
c)2.ClientReferral,Intake, N1311
SS=D Assess,Adm.
Orientation.Theprogramshallprovideorientation
toclientsadmittedfortreatmentwithin24hoursof
admissionoratsuchtimethattheclientappears
abletohearandrespondtorequests,butinno
eventlaterthan72hoursafteradmission.
Orientationshallbedonebyastaffpersonwho
hasbeendeterminedtobequalifiedbyeducation,
training,andexperiencetoperformthetask.The
followinginformationmustbeexplainedtothe
client,anddocumentedintheclient's file.
i)Theexpectedbenefitsofthetreatmentthatthe
clientisexpectedtoreceive;
STATE FORM 6899
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ii) Anexplanationofindividualizedtreatment
planning;
iii) Theclient'sresponsibilitiesforadheringtothe
treatmentplanandtheconsequencesof
non-adherence;
iv) Theidentificationofthestaffpersonthatis
expectedtoprovidetreatmentorcoordinatethe
treatment;
v) Programrulesincludingrequirementsfor
conductandtheconsequencesofinfractions;
vi) Client'sRights,Responsibilities,and
Complaints;
vii) Theprogram's policiesforuseofbehavior
managementandemergencysafetyinterventions
whennecessary; and
viii) Policiesandproceduresforvisitinghours
andcommunicationswithpersonsoutsidethe
program,ifaresidentialprogram.
Basedonreviewofclientrecords,itwas
determinedthatthefacilityfailedtoprovide
orientationtoclientsadmittedtortreatmentwithin
24hours. Findingsinclude:
Thefilesforclient #1-#
4didnotcontain
documentationthattheyreceivedorientationwhen
theywereadmittedtothefacility.
proceed.
N1401111- 8-19-.14(a)IndividualTreatmentPlanning. N1401

SS=D
PreliminaryTreatmentPlan.Aninitialtreatment
STATE FORM 6899
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IDID(
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planwillbeformulatedatthetimeofadmission
afterassessment (withinaminimumoften
workingdays)andwillincludetheinitialtreatment
recommendationfortheclient.Theinitial
treatmentplanmaybedocumentedinthe
programnotes.
interview,thefacilityfailedtoformulatea
preliminarytreatmentplanatthetimeof
admissionafterassessment (withinaminimumof
tenworkingdays). Findingsinclude:
Areviewofclientfilesrevealedthatclients #1,
2,and #4,didnothavedocumentationa
preliminarytreatmentplanatthetimeof
admissionafterassessment (withinaminimumof
tenworkingdays)intheirfiles.
produced.
N1402111- 8-19-.14(b)IndividualTreatmentPlanning. N1402

SS=D
CompleteTreatmentPlan.Thecomplete
treatmentplanmustbecomprehensive,
formulatedbyamulti-disciplinaryteamwiththe
inputoftheclient,approvedbytheclinical
director,completedwithinthirtydaysfrom
admission,andshallcontainsufficientinformation
abouttheclient'sexpectedtreatment\[.\]...
STATE FORM 6899
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435- D10/ 18/ 2018
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IDID(
DEFICIENCY)

interview,thefacilityfailedtoformulatedbya
multi-disciplinaryteamwiththeinputoftheclient,
approvedbytheclinicaldirector,completedwithin
thirtydaysfromadmission,andshallcontain
sufficientinformationabouttheclient'sexpected.
Findingsinclude:
Areviewofclientrecordsrevealedthat
clients#1-# 4,didnothavedocumentationa
completetreatmentplanwasformulatedbya
multi-disciplinaryteamwiththeinputoftheclient,
approvedbytheclinicaldirector,completedwithin
thirtydaysfromadmission,andshallcontain
sufficientinformationabouttheclient's expectedin
theirfile.
produced.
N1416111- 8-19-.14(d)IndividualTreatmentPlanning. N1416

SS=D
Randomurinedrugscreensarerequiredforeach
client,thefrequencyofwhichisdeterminedbythe
programinordertodetermineitseffectiveness.
Clinicaldirectorselectingtorelyuponpresumptive
urinalysisresultsforclientmanagementmust
demonstrateadequateaccesstodefinitive
qualitativelaboratoryanalysisforusewhen
necessary.
Basedonarecordreviewandstaffinterview,
thefacilityfailedtoconductongoingrandomurine
drugscreens. findingsinclude:
Areviewofclientrecordsrevealedthatclient
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1-#4 ,didnothavedocumentationthefacility
conductedongoingrandomdrugscreens.
produced.
N1417111- 8-19-.14(e)IndividualTreatmentPlanning. N1417

SS=D
PlanReviews.Plansshallbereviewedand
updated,asneeded,bythestaffmemberwhohas
primaryresponsibilityforcoordinatingorproviding
forthecareoftheclient.Reviewsshallbedone
whenevernecessaryasindicatedbytheclient's
needsoratleasteverythirty (30)daysfor
residentialandsixty (60)daysforoutpatient.
Authority: O.C.G.A. §§ 26-5-5,26-5-6.
thefacilityfailedtoreviewandupdatetreatment
planseverysixty (60)daysforoutpatientclients.
Findingsinclude:
Reviewofclientrecordsrevealedclient #1-#
4 did
nothavedocumentationthatthetreatmentplans
werereviewedandupdatedatleasteverysixty
days.
inaninterviewon10/18/18at3:00p.m.,staffH
produced.

STATE FORM 6899

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PRINTED: 12/07/2018

060- B.WING _____________________________

N000Initial Comments. N000

STATE FORM 6899

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N928Continued From page 2 N928

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N939Continued From page 3 N939

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N940Continued From page 4 N940

N1006111- 8-19-.10(7)Staffing. N1006

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N1006Continued From page 5 N1006

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N1008Continued From page 6 N1008

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N1008Continued From page 7 N1008

N1103111- 8-19-.11(3)PhysicalPlant &Safety. N1103

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N1103Continued From page 8 N1103

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N1302Continued From page 9 N1302

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N1303Continued From page 10 N1303

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N1303Continued From page 11 N1303

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N1304Continued From page 12 N1304

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N1311Continued From page 13 N1311

N1401111- 8-19-.14(a)IndividualTreatmentPlanning. N1401

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N1401Continued From page 14 N1401

N1402111- 8-19-.14(b)IndividualTreatmentPlanning. N1402

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N1402Continued From page 15 N1402

N1416111- 8-19-.14(d)IndividualTreatmentPlanning. N1416

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N1417111- 8-19-.14(e)IndividualTreatmentPlanning. N1417

State of GA Inspection Report

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