INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17, 2021 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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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 five of seven client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in client records # 1, 2, 3, 6, and 7. Client # 1 was admitted on September 27, 2021 and was still active at the time of the inspection. A treatment plan developed on September 27, 2021 indicated a 6.5 weekly type and frequency of services. The record of service and progress notes indicate the following:September 27-October 4-0 groups and 1 individual sessionOctober 4-11-0 individual and 0 group sessionsOctober 11-18-1 individual and 0 group sessionsOctober 18-25-0 individual and 1 group sessionOctober 25-November 1-1 individual and 3 group sessionsNovember 1-8-0 individual and 2 group sessionsNovember 8-15-1 individual and 1 group sessionClient # 2 was admitted on July 12, 2021 and was still active at the time of the inspection. A treatment plan developed on July 12, 2021 indicated a 9.0 weekly type and frequency of services. A treatment plan update on September 15, 2021 indicated a 7.0 weekly type and frequency of services. The record of service and progress notes indicate the following:July 12-19 -0 individual and 0 group sessionsJuly 19-26 -1 individual and 0 group sessionsJuly 26-August 2 -1 individual and 1 group sessionAugust 2-9 -2 individual and 1 group sessionsAugust 9-16- 0 individual and 0 group sessionsAugust 16-23 -1 individual and 1 group sessionAugust 23-30 -1 individual and 1 group sessionAugust 30-September 9 -0 individual and 0 group sessionSeptember 9-13 -1 individual and 1 group sessionSeptember 13-November 1 -0 individual and 0 group sessionNovember 1-8- 1 individual and 0 group sessionsNovember 8-15- 1 individual and 1 group sessionClient # 3 was admitted on August 30, 2021 and was still active at the time of the inspection. A treatment plan developed on August 30, 2021 indicated a 9.0 weekly type and frequency of services. A treatment plan update on October 20, 2021 indicated a 6.5 weekly type and frequency of services. The record of service and progress notes indicate the following:August 30-September 6 -1 individual and 1 group sessionsSeptember 6-13 -1 individual and 0 group sessionsSeptember 13-20 -1 individual and 3 group sessionSeptember 20-27 -1 individual and 2 group sessionSeptember 27-October 4 -1 individual and 1 group sessionOctober 4-11 -1 individual and 0 group sessionOctober 11-18 -1 individual and 2 group sessionOctober 18-25 -1 individual and 2 group sessionOctober 25-November 1 -0 individual and 3 group sessionNovember 1-8 -0 individual and 3 group sessionNovember 8-15 -0 individual and 2 group sessionClient # 6 was admitted on July 14, 2021 and was discharged on November 15, 2021. A treatment plan developed on July 14, 2021 indicated a 9.0 weekly type and frequency of services. A treatment plan update on September 27, 2021 indicated a 4.5 weekly type and frequency of services. The record of service and progress notes indicate the following:July 14-21 -1 individual and 1 group sessionsJuly 21-28 -1 individual and 0 group sessionsJuly 28-August 4 -1 individual and 1 group sessionAugust 4-11 -2 individual and 1 group sessionAugust 11-18 -2 individual and 1 group sessionAugust 18-25 -0 individual and 0 group sessionAugust 25-September 1 -0 individual and 1 group sessionSeptember 1-8 -0 individual and 1 group sessionSeptember 8-15 -2 individual and 0 group sessionSeptember 15 -22 -0 individual and 1 group sessionSeptember 22-29 -0 individual and 0 group sessionSeptember 29-October 6 -0 individual and 0 group sessionOctober 6-13 -0 individual and 0 group sessionOctober 13-20 -0 individual and 0 group sessionOctober 20-27 -0 individual and 1 group sessionOctober 27-November 3 -0 individual and 1 group sessionNovember 3-10 -0 individual and 0 group sessionClient # 7 was admitted on June 8, 2021 and was discharged on October 1, 2021. A treatment plan developed on June 8, 2021 indicated a 9.0 weekly type and frequency of services. A treatment plan update on August 6, 2021 indicated a 7.0 weekly type and frequency of services. The record of service and progress notes indicate the following:June 8-15 -1 individual and 0 group sessionsJune 15-22 -1 individual and 0 group sessionsJune 22-29 -0 individual and 0 group sessionsJune 29-July 6 -1 individual and 0 group sessionsJuly 6-13 -1 individual and 0 group sessionsJuly 13-20 -0 group sessionsJuly 20-27 -0 individual and 0 group sessionsJuly 27-August 3 -1 individual and 0 group sessionAugust 3-10 -0 individual and 0 group sessionAugust 10-17 -0 individual and 0 group sessionAugust 17-24 -1 individual and 0 group sessionAugust 24-31 -2 individual and 0 group sessionAugust 31-September 7 -1 individual and 0 group sessionSeptember 7-14 -2 individual and 0 group sessionSeptember 14-21 -1 individual and 0 group sessionSeptember 15 -22 -0 individual and 1 group sessionSeptember 21-28 -2 individual and 0 group sessionThese findings were reviewed with facility staff during the licensing process.
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Plan of Correction
According to PA Code 709.92 (c), clients need to be following their treatment plan requirements as it is stated on their individual treatment plans. When a client does not follow the treatment plan it is to be documented on the record of service as well as noted in the client's file of the non-compliance.
Regarding client charts within A Better Today moving forward, all client charts will note the non-compliance on what the facility calls a "blue note" (equivalent to a case management note) by documenting the missing sessions, whether group and/or individual sessions (no shows, cancels, and reschedules). Also, for documentation purposes the record of service form that is in each client's file will have the written recording of stated no shows, cancels, and/or reschedules.
It is very important for a client to following their treatment plan to obtain the best possible care. Continued conversations with the client and if they have oversight is pivotal. Documentation on the "blue note" will indicate those conversations as well within their individual session notes. If a client is struggling to make the treatment that is required of them, case consultation will be done between Clinical Director and counselor with the client to see if the treatment plan needs to be changed.
Responsible for these actions: Counselors on the individuals case as well as Clinical Director to assure above is being performed and completed.
Corrective action to be affect as of: 12/20/2021
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on five of seven client records reviewed, the facility failed to provide a complete client record to include the documentation of services on the record of service in client records # 2, 3, 4, 5, and 6.Client # 2 was admitted on July 12, 2021 and was still active at the time of the inspection. Progress notes dated July 20, 27, 28, August 3, 6, 17, 24, 25, September 7, and 14 were not documented on the record of service.Client # 3 was admitted on August 30, 2021 and was still active at the time of the inspection. Progress notes dated October 26, 27 were not documented on the record of service.Client # 4 was admitted on July 2, 2021 and was still active at the time of the inspection. Progress notes dated August 24 and September 14 were not documented on the record of service.Client # 5 was admitted on April 6, 2021 and was discharged on August 19, 2021. Progress notes dated July 12 was not documented on the record of service.Client # 6 was admitted on July 14, 2021 and was discharged on November 15, 2021. Progress notes dated September 28 was not documented on the record of service.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include a record of service documenting all services provided to the client, the Clinical Director has put together a meeting with all clinical staff to discuss documentation within the chart and what needs to be done moving forward.
All client charts moving forward will be documented correctly. Showed appointments/no shows/reschedules/cancellations to be noted on the record of service for group and individual sessions, especially for showed progress notes that are in the chart.
Documentation has to be clearly documented as such if the session was a group or individual session. Record of service and notes per client deficiencies with be documented/re-done to adhere to corrections. |