INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 8, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Rehab After Work 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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709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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 complete an individual treatment and rehabilitation plan within the timeframe documented in the facility policy and procedure manual in five of seven client records reviewed.
The policy and procedure manual stated that the comprehensive treatment plan will be completed within 7 days of the level of care assessment.
Client #1 was admitted to the partial hospitalization activity on July 11, 2022 and was discharged on September 5, 2022. The level of care assessment was completed on July 11, 2022; however, the comprehensive treatment plan was completed on July 28, 2022.
Client #2 was admitted to the partial hospitalization activity on December 6, 2022 and was discharged on January 4, 2023. The level of care assessment was completed on December 6, 2022; however, the comprehensive treatment plan was completed on December 15, 2022.
Client #3 was admitted to the partial hospitalization activity on June 9, 2022 and was discharged on July 10, 2022. The level of care assessment was completed on June 9, 2022; however, the comprehensive treatment plan was completed on June 21, 2022.
Client #5 was admitted to the partial hospitalization activity on January 11, 2023 and was active at the time of inspection. The level of care assessment was completed on January 11, 2023; however, the comprehensive treatment plan was completed on January 26, 2023.
Client #6 was admitted to the partial hospitalization activity on February 6, 2023 and was active at the time of inspection. The level of care assessment was completed on February 6, 2023; however, the comprehensive treatment plan was completed on February 16, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and executive director with the support of clinical director and quality manager will complete monthly chart audits to ensure treatment plans are being completed within policy timeframes. Re-training will occur during group supervision within 30 days, with expectation of full compliance by 6/8/23. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every thirty days in three of five applicable client records reviewed.
Client #1 was admitted to the partial hospitalization activity on July 11, 2022 and was discharged on September 5, 2022. The comprehensive treatment plan was completed on July 28, 2022, and the first update was due no later than August 28, 2022; however, the update was completed on September 2, 2022.
Client #4 was admitted to the partial hospitalization activity on June 13, 2022 and was discharged on July 26, 2022. The comprehensive treatment plan was completed on June 21, 2022, and the first update was due no later than July 21, 2022; however, the update was not completed prior to discharge.
Client #5 was admitted to the partial hospitalization activity on January 11, 2023 and was active at the time of inspection. The comprehensive treatment plan was completed on January 26, 2023, and the first update was due no later than February 26, 2023; however, the update was completed on March 7, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and executive director with the support of clinical director and quality manager will complete monthly chart audits to ensure treatment plan updates are being completed within policy timeframes. Re-training will occur during group supervision within 30 days, with expectation of full compliance by 6/8/23. |