INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on April 30, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, A Better Today Inc. 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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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from January 2024 - April 2024, the facility failed to prepare alternative exit route to be used during fire drills, as all drills utilized both exit routes during all drills.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October 18, 2023 licensing inspection.
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Plan of Correction
Starting May 22, 2024, when holding fire drills staff will alternate which exit everyone is directed to during the fire drill; front entrance or back entrance.
Counselor(s) responsible for running the fire drill will yell to direct everyone involved to the same exit.
Clinical Supervisors will monitor the monthly fire drills to ensure ongoing compliance.
Responsible for these actions: Clinical Supervisors and Counselors. |
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 outpatient client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client in three out of six applicable records reviewed.
Client #2 was admitted on January 8, 2024 and was still active at the time of the inspection. No treatment plan was developed.
Client #6 was admitted on February 28, 2024 and was still active at the time of the inspection. No treatment plan was developed.
Client #7 was admitted on February 12, 2024 and was still active at the time of the inspection. No treatment plan was developed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Better Today, Inc.(ABT) has begun a staff training program to ensure our clinical documentation meets the standards of ABT. Clinical Supervisors are now conducting ongoing training on ABT documentation policies. We are continuing to provide training and have a quality assurance team in place to find these errors and return them to the counselors so they are able to see and learn from the mistakes they are making.
As we continue to teach our incoming staff this procedure will assure that all new treatment plans are individualized to each client. We will continue to use the standardized plans that are mandatory for each client and add their individualized plans as well. This process is currently ongoing and will be monitored on a monthly basis during the quality assurance team's chart reviews. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that the individual treatment and rehabilitation plan included proposed type of support service in three out of three applicable records reviewed.
Client #1 was admitted on January 4, 2024 and was still active at the time of the inspection. A treatment plan was completed on January 4, 2024.
Client #3 was admitted on March 6, 2024 and was still active at the time of the inspection. A treatment plan was completed on March 6, 2024.
Client #5 was admitted on December 18, 2023 and was still active at the time of the inspection. A treatment plan was completed on December 18, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 18, 2023 licensing inspection.
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Plan of Correction
As of 4/30/2024, Master Treatment Plan and Treatment Plan Updates have been edited to include a section for counselors to document client support outside their treatment.
Clinical supervisor(s) will check client charts weekly to ensure Master Treatment Plan and Treatment Plan Updates include a section for counselors to document client support outside their treatment.
Responsible for these actions: Clinical Supervisor and Counselors. |
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 regulatory timeframe in two out of three applicable records reviewed.
Client #4 was admitted on November 21, 2023 and was still active at the time of the inspection. A treatment plan was completed on November 21, 2023 and an update was due no later than January 21, 2024; however, none was completed.
Client #5 was admitted on December 18, 2023, 2023 and was still active at the time of the inspection. A treatment plan was completed on December 18, 2023 and an update was due no later than February 18, 2024; however, it was not completed until April 18, 2024.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October18, 2023 licensing inspection.
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Plan of Correction
Our policy is to keep treatment plans and treatment plan updates in a separate chart until they can be reviewed by our medical director. This usually takes place on a weekly basis and the treatment plans are then filed in the clinical charts. However our medical director was on vacation and the treatment plans were left out of the chart pending review longer than expected.
Our medical director has since returned and all treatment plans and updates are once again being reviewed and filed on a weekly basis. All of the past treatment plans that were out of the charts have now been filed. We have spoken to the doctor about this matter and he will refer us to the doctor that covers for him when and if a similar situation ever occurs in the future. This will be an ongoing plan.
Clinical supervisor(s) will check client charts weekly to ensure Master treatment plans and treatment plan updates are signed, dated, and returned by the medical director promptly.
Responsible for these actions: Medical Director, Clinical supervisors, and Counselors. |