INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 17, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center Inc, Moffett House 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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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan which included documentation of the type and frequency of treatment and rehabilitation services in two of four client records.
The findings include;
Eight client records were reviewed on January 7-9 and 17, 2013. Four client records required documentation of an individual treatment and rehabilitation plan which included documentation of the type and frequency of treatment and rehabilitation services. There was no documentation of the type and frequency of treatment and rehabilitation services in client records # 6 and 7.
Client # 6 was admitted on October 11, 2012. An individual treatment and rehabilitation plan was completed on October 11, 2012. The plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 7 was admitted on December 6, 2012. An individual treatment and rehabilitation plan was completed on December 7, 2012. The plan did not include documentation of the type and frequency of treatment and rehabilitation services.
The Clinical Supervisor was interviewed on January 17, 2013 and confirmed the findings.
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Plan of Correction
The Director met with Clinical manager to discuss the documentation of individualizes treatment services at Moffett House. The clinical manager will meet with therapist to review the individualizing of client's treatment plans and the documentation of type and frequency of services in monthly supervision. Therapist will review treatment plans in weekly clinical with manager. This will ensure that type and frequency of services are being maintained. The clinical manager will complete random monthly audits of client's records ensuring that individualized treatment and rehabilitation plans are documented and maintained in timely manner.
The director will assist in completing random audit of client's records. The director and clinical manager will collaborate in developing training for therapist enhancing documentation and completion of individualizes treatment and rehabilitation plans.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records, the facility failed to document a treatment plan update which included the client's progress or lack of progress on the stated treatment goals and objectives in four of four client records.
The findings include:
Eight client records were reviewed on January 7-9 and 17, 2013. Four client records were reviewed for the completion of treatment and rehabilitation plan updates. The facility did not document treatment and rehabilitation plan updates which included the client's progress or lack of progress on the stated goals and objectives in client records # 5, 6, 7 and 8.
Client # 5 was admitted on September 28, 2012. Treatment plan updates were completed on October 29, November 29 and December 28, 2012. The updates listed only "active", "reassigned" or "completed" for each goal listed on the comprehensive treatment plan and did not address the progress on the stated goals of the treatment plan.
Client # 6 was admitted on October 11, 2012. Treatment plan updates were completed on November 14, December 10, 2012 and January 10, 2013. The updates listed only "active", "reassigned" or "completed" for each goal listed on the comprehensive treatment plan and did not address the progress on the stated goals of the treatment plan.
Client # 7 was admitted on December 6, 2012. A treatment plan update was completed on January 6, 2013. The update listed only "active", "reassigned" or "completed" for each goal listed on the comprehensive treatment plan and did not address the progress on the stated goals of the treatment plan.
Client # 8 was admitted on October 10, 2012. Treatment plan updates were completed on November 13 and December 13, 2012 and January 13, 2013. The updates listed only "active", "reassigned" or "completed" for each goal listed on the comprehensive treatment plan and did not address the progress on the stated goals of the treatment plan.
The Clinical Supervisor was interviewed on January 17, 2013 and confirmed the findings.
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Plan of Correction
The Director and Clinical manager of Moffett House met to discuss issues regarding treatment plan updates. The Clinical manager will meet with therapist during weekly supervision to review the implementation of a client progress or lack of progress onto the goals identified in treatment plan updates.
The clinical manager will do monthly audits of client's treatment plans ensuring that goals, overall progress or lack of progress are being documented. Therapists will review treatment plans updates with clinical manager during weekly clinical reviews. This will ensure that client's treatment plan updates clearly reflects overall progress while at Moffett House. The reviews will ensure that treatment updates are maintained or modified in timely manner.
The director and clinical manager will work on developing trainings that can enhance treatment planning, Treatment updated and documentation for therapist. The director will also assist in monitoring of treatment plans updates. This will ensure that treatment plan updates are meeting recommendations.
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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 the review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in four of four client records.
The findings include:
Eight client records were reviewed on January 7-9 and 17, 2013. Four client records were reviewed for compliance with the assurance that counseling services were provided according to the individual treatment and rehabilitation plan. The facility did not document compliance in client records # 5, 6, 7 and 8.
Client # 5 was admitted on September 28, 2012. The individual treatment and rehabilitation plan, completed on October 29 and updates completed on November 29 and December 28, 2012 stated the client was to receive one individual counseling session per week. There was no documentation of an individual counseling session for the weeks of October 7, 14, 21, November 4, 18, December 2 and 16, 2012.
Client # 6 was admitted on October 11, 2012. The individual treatment and rehabilitation plan, completed on October 11 and updates completed on November 14, December 10, 2012 and January 6, 2013 did not include documentation of the type and frequency of the treatment and rehabilitation services the client was to receive. It was not possible to determine if the client was receiving services according to the individual treatment and rehabilitation plan.
Client # 7 was admitted on December 6, 2012. The individual treatment and rehabilitation plan, completed on December 7, 2012 and an update completed on January 6, 2013 did not include documentation of the type and frequency of the treatment and rehabilitation services the client was to receive. It was not possible to determine if the client was receiving services according to the individual treatment and rehabilitation plan.
Client # 8 was admitted on October 10, 2012. The individual treatment and rehabilitation plan, completed on October 11 and updates completed on November 13 and December 13, 2012 and January 13, 2013 stated the client was to receive one individual counseling session per week. There was no documentation of an individual counseling session for the weeks of October 21, November 4, 18 and December 23, 2012.
The Clinical Supervisor was interviewed on January 17, 2013 and confirmed the findings.
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Plan of Correction
The Director and Clinical manager of Moffett House met to discuss proper documentation of counseling services received by clients. The clinical manager will meet with therapist to review all treatment plans during monthly supervision. This will ensure that treatment plans expectations are being followed or modified if required. During weekly clinical meetings therapist and clinical manager will review client's treatment progress. This will ensure that treatment plans accurately reflect the client's treatment status. Clinical manager will review type and frequencies identified in treatment and rehabilitation plan. This to ensure that client's and therapist are meeting goals of treatment plan. The clinical manager will review the documentation of services provided for client during treatment stay. This will ensure that therapist is documenting services identified on client treatment plans.
The director and clinical manager will complete random audits of client's treatment plans. This will ensure that type and frequency of services are being documented and overall treatment process meets client's progress.
The director and clinical manager will address proper documentation of counseling services provided on treatment plans, in staff training.
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