INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 18, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, White Deer Run of York was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 a review of client records, the facility failed to provide a treatment and rehabilitation plan that included the type and frequency of services.Client # 3 was admitted on December 20, 2023, and was still an active participant at the time of the investigation. Treatment plans dated 12/22/23, 1/3/24 and 1/17/24 were missing documentation of the type and frequency of services.
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Plan of Correction
The individual's treatment plan, that is developed with the client, will include. type and frequency of treatment services.
Clinical Director met with the counselor, as well as the counseling team and provided education on this requirement.
Counselor will meet with the client identified and document type and frequency on Treatment plane addendum note for plans 12/22/23, 1/3/24, and 1/17/24.
Clinical Director will be pulling random charts weekly over next 60 days to check for this and checking ongoing on our monthly chart reviews. |
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 assure that counseling services are provided according to the individual treatment and rehabilitation plan in one of five charts reviewed. Client # 1 was admitted on July 16, 2023, and discharged on August 22, 2023. The master treatment plan dated 7/24/23 indicated 1 individual session per week. There were no individual session progress notes for the weeks of 7/23/23, 7/30/23, and 8/13/23.
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Plan of Correction
All Clients are to receive and counseling services as indicated on their individual treatment plan.
Clinical Director met with counselor of client identified (client 1) and discussed the importance of documentation, creating a plan with counselor to ensure documentation is entered.
Clinical director will be checking counselors' documentation of sessions weekly over the next 60 days, and then ongoing in chart reviews.
Client is no longer at facility no further action with client.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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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 is to include case consultation notes in one of five records reviewed.According to the Case Consultation Note/Transition Plan policy, residential patients will have a minimum of one case consultation during the course of treatment.Client # 1 was admitted on July 16, 2023, and discharged on August 22, 2023. This client record did not contain documentation of a case consultation.
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Plan of Correction
Case Consultations will be completed during weekly clinical meetings and added to the electronic record.
Clinical Director will develop a check list to ensure all clients are getting a minimum of one consultation during their course of treatment.
Clinical director will review this procedure with the team and monitor case consults weekly ongoing.
Client #1 identified is no longer at the program so no further action can occur with that record. |
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 provide a complete client record on an individual, which is to include follow-up information in one of five records reviewed.Per the Patient Follow-up policy, a designated staff member will attempt to contact the former patient within 30 business days after discharge for patients discharged with no referral. Client # 1 was admitted on July 16, 2023, and discharged on August 22, 2023. This client record did not contain documentation of follow-up information.
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Plan of Correction
Follow ups with all discharged clients will be completed as per our follow up policy, by a member of our clinical team. Follow ups will be uploaded into the electronic record by the counselor.
Director and Clinical Director reviewed the follow up policy with the clinical team.
Clinical Director will review weekly for the next 3 months all discharges to check for the follow up forms when completed.
The follow up forms, are being added to the client monthly chart audits for ongoing compliance. |
709.54(b) LICENSURE Aftercare policy
709.54. Project management services.
(b) The project shall develop a written client aftercare policy.
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Observations
Based on a review of client records, the facility failed to follow its aftercare policy in one of five records reviewed.The Continuing Care/Transition Plan policy dictates the primary counselor, with the patient's input, is responsible for the completion of the plan. Prior to discharge, the patient and counselor will meet to finalize the plan. Client # 1 was admitted on July 16, 2023, and discharged on August 22, 2023. The aftercare plan was missing the client signature signifying the client had input and the plan was finalized with the client.
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Plan of Correction
Clinician will complete the continuing care plan (aftercare plan) with the clients input and have the client sign off that they participated in the plan.
Clinical Director will educate the clinicians on the proper completion of the continuing care plan(after care).
For the next 60 days clinical director and or assistant director will review discharged charts to ensure continuing care plans are signed off.
Continued compliance will be monitored by including the continuing care plan (after care) in the chart reviews. |