INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 21-22, 2024by
staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based
on the findings of the on-site inspection, Clearbrook Treatment Centers, LLC d/b/a Huntington Creek Recovery Center 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of detox and residential client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in three of five applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in DDAP Licensing Alert 02-21.
Client # 4 was admitted to the inpatient non-hospital detoxification activity on June 7, 2024, and was discharged against medical advice on June 9, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #7 was admitted to the inpatient non-hospital detoxification activity on February 13, 2024, and was discharged against medical advice on February 17, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #11 was admitted to the inpatient non-hospital rehabilitation activity on March 5, 2024, and was discharged against medical advice on March 11, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services or designee will conduct a mandatory training of all inpatient counselors to ensure that staff understand, notify, and document outreach to the EMC in the event of a client's AMA/ACA discharge. The training will be completed by 12/15/2024.
The Director of Clinical Services or designee will retain the training certificates and/or training signature sheets and will provide copies to the Director of Q&PI by 12/31/2024.
Compliance will be regularly monitored by the Medical Records Clerk and/or the Director of Clinical Services or designee. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of inpatient client records, the facility failed to document proposed type of support service on individual treatment plans in seven out of seven client records reviewed.
Client #8 was admitted August 26, 2024 and was still active at the time of the inspection
Client #9 was admitted on September 11, 2024 and was still active at the time of the inspection.
Client #10 was admitted on September 10, 2024 and was still active at the time of the inspection.
Client #11 was admitted on March 5, 2024 and was discharged on March 11, 2024
Client #12 was admitted on August 5, 2024 and was discharged on August 21, 2024.
Client #13 was admitted on July 12, 2024 and was discharged on August 28, 2024.
Client #14 was admitted on September 7, 2024 and was discharged on October 3, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A section for support services will be added to the Discharge Planning section of the Master Treatment Plan by 11/30/24. The Director of Clinical Services or designee will provide instruction to clinical staff on completion of this section by 12/15/24.
Compliance will be regularly monitored by the Medical Records Clerk and/or the Director of Clinical Services or designee. |