INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 25, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Passages to Recovery 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(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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in three of the six applicable client records reviewed.
Client #3 was admitted on November 24, 2021 and was still active at the time of the inspection. A treatment plan update was completed on November 24, 2021, and the next update was due no later than January 24, 2022; however, there was no update documented in the record until April 6, 2022.
Client #5 was admitted on August 2, 2021 and discharged on May 24, 2022. A treatment plan update was completed on August 27, 2021, and the next update was due no later than October 27, 2021; however, there was no update documented in the record until November 5, 2021.
Client #7 was admitted on January 29, 2020 and was discharged on April 14, 2022. A treatment plan update was completed on October 26, 2021, and the next update was due no later than December 26, 2021; however, there was no update documented in the record at the time of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery, Outpatient Department has begun the implementation of a new EHR effective June 1, 2022 called Clinic Tracker. The Clinic Tracker system will track all treatment plan due dates and has a built in compliance feature that will send a notification to both the Therapist and Supervisor to notify them of when a treatment plan is nearing update and/or when it is overdue. This feature, in addition to regular audits by the Management team, will ensure that treatment plans are completed within the required time frames.
Client #3 treatment plan updates were completed via telehealth for plan updates for 1/22 and 3/24. Client was discharged on 5/26/22.
Client #5 was discharged on 5/24/22 due to inactivity. Treatment plans were updated to reflect clients non compliance to treatment attendance and recommendations.
Client #7 treatment plans for 12/21 and 2/22 were updated to reflect clients non compliance to treatment attendance and recommendations. Client was discharged on 4/22. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of seven outpatient client records, the facility failed to provide a complete client record, which is to include a discharge summary in one of the three applicable client records reviewed.
Client #7 was admitted on January 29, 2020 and was discharged on April 14, 2022. There was no documentation of a discharge summary being completed in the client record.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery, Outpatient Department has begun the implementation of a new EHR effective June 1, 2022 called Clinic Tracker. The Clinic Tracker system will track all required client discharges/discharge summaries and has a built in compliance feature that tracks when discharges are due and allow for proper documentation of said discharge. This feature, in addition to regular audits by the Management team, will ensure that treatment plans are completed within the required time frames.
Client #7's discharge was completed and submitted to the EHR and documentation is available upon request. |
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 the facility ' s policy and procedure manual and seven client records, the facility failed to complete, and document follow up information in one of three applicable client records.
Client #6 was admitted on January 28, 2022 and was discharged on April 23, 2022. There was no documentation of a follow up being completed within the client record.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery, Outpatient Department has begun the implementation of a new EHR effective June 1, 2022 called Clinic Tracker. The Clinic Tracker system will track all required client discharges and follow ups based upon the timeframe documented in the policy and procedure manual. The system has a built in compliance feature that tracks when discharges are due and allow for proper documentation of said discharge. This feature, in addition to regular audits by the Management team, will ensure that treatment plans are completed within the required time frames.
Client #6's discharge paperwork was completed and submitted to the EHR on 4/23/22. Documentation can be provided upon request. |