INITIAL COMMENTS
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This report is a result of an off-site complaint investigation conducted on May 6, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the off-site complaint investigation, Pennsylvania Care LLC dba Miners Medical 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of patient records, the facility failed to notify a client, in writing, of the facility's decision to involuntarily terminate the client in 1 of 1 record reviewed.
Client # 1 was admitted on 11/7/24 and discharged on 3/24/25.
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Plan of Correction
Training and Education Efforts: Objective: Staff must notify the client, in writing, of a decision to involuntarily discharge them from the program within 24hours of the decision to discharge. Staff must also document the decision of the discharge into the client's chart within 24hours. Staff will notify the Executive Director for the reason of the discharge and approve/deny the discharge on a client-by-client basis.
Clinical Supervisor, Lead Counselor, or Executive Director will provide a 1-hour training on why timely documentation is important. A 1-hour training on the discharge process will begiven to all current and future staff. A checklist will be provided to all staff to ensure the discharge procedure is followed accurately and this checklist will be used for each case determined involuntary discharge to ensure compliance. This document will be monitored by the lead counselor. A quarterly audit will be conducted to ensure any discrepancies or non-compliant documentation. This document will be monitored by the clinical Director or Lead Counselor. A chart review will be documented in iAuditor using the pt service review tool. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 patient records, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in one of one record reviewed.
Client # 1 was admitted 11/7/24 and discharged 3/24/25. The treatment plan dated 11/7/24 - 12/7/24, indicated 2.5 hours of individual and group counseling monthly. The progress notes indicate the client received one individual session on 11/7/24 for 60 minutes. The next service was dated 12/10/24.
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Plan of Correction
Lead counselor, Clinical Director, and or Executive Director will provide a 1-hour training assessing the need of the client and their treatment hours in order to provide quality services to the client. "Beyond Therapy: The Basics of Clinical Documentation." This will encourage staff awareness and provide them the skills to assess and determine client's needs and objectives.
This document will be monitored by the lead counselor. A quarterly audit will be conducted to ensure any discrepancies or non-compliant documentation. This document will be monitored by the clinical Director or Lead Counselor. A chart review will be documented in iAuditor using the pt service review tool. |