INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 26, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, St. Joseph Institute, LLC 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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709.92(a) 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:
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client, in seven out of seven client records.
Client #1 was admitted on June 3, 2024, and was discharged on July 9, 2024. A comprehensive treatment plan was developed by the clinician on June 8, 2024, but it did not contain a client signature or date.
Client #2 was admitted on February 5, 2024, and was discharged on June 3, 2024. A comprehensive treatment plan was developed by the clinician on February 7, 2024, but it did not contain a client signature or date.
Client #3 was admitted on October 10, 2023, and was discharged on January 4, 2024. A comprehensive treatment plan was developed by the clinician on October 13, 2023, but it did not contain a client signature or date.
Client #4 was admitted on September 8, 2023, and was discharged on August 11, 2024. A comprehensive treatment plan was developed by the clinician on September 11, 2023, but it did not contain a client signature or date.
Client #5 was admitted on September 15, 2023, and was discharged on November 28, 2023. A comprehensive treatment plan was developed by the clinician on September 20, 2023, but it did not contain a client signature or date.
Client #6 was admitted on November 30, 2023, and was discharged on July 1, 2024. A comprehensive treatment plan was developed by the clinician on December 3, 2023, but it did not contain a client signature or date.
Client #7 was admitted on December 28, 2023 and was discharged on July 1, 2024. A comprehensive treatment plan was developed by the clinician on January 3, 2024, but it did not contain a client signature or date.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Outpatient Services will be re-trained by the facility's HCS Superuser on the importance of following through with the documentation on the treatment plan/client record and facility policy on 12/6/2024. The Director of Outpatient will sign attestation forms acknowledging the education/training they received. The Director of Outpatient will complete and submit audits of the charts on a weekly basis for 3 months to ensure 100% compliance. After the 3 months, compliance will be monitored through monthly chart audits. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the timeframes established by its policy, in seven out of seven records reviewed. The facility's policy dictates that treatment plans will be updated every thirty days.
Client #1 was admitted on June 3, 2024, and was discharged on July 9, 2024. There was no documentation of a treatment plan update in this client record.
Client #2 was admitted on February 5, 2024, and was discharged on June 3, 2024. There was no documentation of a treatment plan update in this client record.
Client #3 was admitted on October 10, 2023, and was discharged on January 4, 2024. There was no documentation of a treatment plan update in this client record.
Client #4 was admitted on September 8, 2023, and was discharged on August 11, 2024. There was no documentation of a treatment plan update in this client record.
Client #5 was admitted on September 15, 2023, and was discharged on November 28, 2023. There was no documentation of a treatment plan update in this client record.
Client #6 was admitted on November 30, 2023, and was discharged on July 1, 2024. There was no documentation of a treatment plan update in this client record.
Client #7 was admitted on December 28, 2023, and was discharged on July 1, 2024. There was no documentation of a treatment plan update in this client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Outpatient Services will be re-trained by the facility's HCS Superuser on the importance of following through with the documentation on the treatment plan/client record and facility policy on 12/6/2024. The Director of Outpatient will sign attestation forms acknowledging the education/training they received. The Director of Outpatient will complete and submit audits of the charts on a weekly basis for 3 months to ensure 100% compliance. After the 3 months, compliance will be monitored through monthly chart audits. |
709.93(a)(11) 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:
(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, which is to includes follow-up information in seven out of seven discharged records reviewed. The facility's policy is to follow-up with clients within seven days of discharge.
Client #1 was admitted on June 3, 2024, and was discharged on July 9, 2024. There was no documentation of a follow-up contact in the client record.
Client #2 was admitted on February 5, 2024, and was discharged on June 3, 2024. There was no documentation of a follow-up contact in the client record.
Client #3 was admitted on October 10, 2023, and was discharged on January 4, 2024. There was no documentation of a follow-up contact in the client record.
Client #4 was admitted on September 8, 2023, and was discharged on August 11, 2024. There was no documentation of a follow-up contact in the client record.
Client #5 was admitted on September 15, 2023, and was discharged on November 28, 2023. There was no documentation of a follow-up contact in the client record.
Client #6 was admitted on November 30, 2023, and was discharged on July 1, 2024. There was no documentation of a follow-up contact in the client record.
Client #7 was admitted on December 28, 2023 and was discharged on July 1, 2024. There was no documentation of a follow-up contact in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 12/8/2024, The Alumni Coordinator will be trained by the Director of Business Development on the requirement to follow-up within the facility's policy of 7 days of discharge. The Director of Business Development will monitor for 100% compliance by monthly chart audits.
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