INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25, 2022, 2022 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(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 two of six applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records # 3 and # 7.
Client # 3 was admitted on August 22, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on August 22, 2022. A treatment and rehabilitation plan update was due no later than October 22, 2022 however, there was no documentation of a treatment plan update in the client record.
Client # 7 was admitted on December 29, 2021 and was discharged March 15, 2022. A treatment and rehabilitation plan was developed on December 29, 2021. A treatment and rehabilitation plan update was due no later than February 28 or March 1, 2022 however, there was no documentation of a treatment plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 19, 2021 annual licensing inspection.
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Plan of Correction
According to PA Code 709.92 (b): Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. In two of the charts upon review there was a failure to do so.
Counselors are responsible to assure that they update the client's treatment plan on or before 60 days. The counselor and Clinical Director will have weekly client census meetings to go over each client on each counselors case load. Projected treatment plan update dates will be added to the clinical census next to each client name so then on a weekly basis the counselor and Clinical Director are aware of the treatment plans that have to be updated. Those dates will change before or on the 60 day mark from admission forward when the treatment plan is executed and will reflect on that clinical census. In addition, the Clinical Director will do every month checks in client charts to make sure treatment plans and case consults have been done in the appropriate timeframe and are in the chart. Furthermore, each treatment plan update will be blue noted to match what is in the client chart.
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 effect as of: 12/1/2022
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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 six applicable 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, 4, and 7.
Client # 1 was admitted on June 7, 2022 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was developed with the client on June 7, 2022 and indicated three groups and one individual session a week. A review of progress notes and record of service indicated the weeks of June 7 through August 6, sixteen of twenty-four required groups documented. A treatment plan update occurred August 7, 2022 and indicated one group and one individual a week. A review of progress notes and record of service indicated the weeks of August 7 through October 6, four of eight required groups documented.
Client # 2 was admitted on July 15, 2022 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was developed with the client on July 15, 2022 and indicated two groups and one individual a week. A review of progress notes and record of service indicated the weeks of July 15 through September 13, three of the required sixteen groups and three of the required eight individual sessions documented.
Client # 3 was admitted on August 22, 2022 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was developed with the client on August 22, 2022 and indicated four groups and one individual a week. A review of progress notes and record of service indicated no group or individual sessions documented.
Client # 4 was admitted on May 2, 2022 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was developed with the client on May 2, 2022 and indicated four groups and one individual a week. A review of progress notes and record of service indicated the weeks of May 2 through July 1, three of the required twenty-four groups and four of the required eight individual sessions documented.
Client # 7 was admitted on December 29, 2021 and was discharged March 15, 2022. An individual treatment and rehabilitation plan was developed with the client on December 29, 2021 and indicated two groups and one individual a week. A review of progress notes and record of service indicated the weeks of December 29 through February 28, one of the required sixteen groups and four of the required eight individual sessions documented.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 19, 2021 annual licensing inspection.
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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.
To assure that this is will not happen again the Clinical Director will be implementing the following:
1. Consistent weekly clinical census meetings to assure that each counselor in stated office is on top of clinical documentation and client treatment--census shows who is compliant versus non-compliant--log of these meetings
2. All staff across all ABT offices to have a staff meeting at the Scranton office every 3 months to assure that all staff are on the same page in regards to documentation, any clinical issues/questions, treatment adherence, etc.--log of these meetings
3. Clinical Director to do client chart checks every month to make sure the counselor is documenting the client's treatment correctly---Clinical Director has created a client checklist that will be used when checking each chart--any discrepancies will be put on the check list as well as helpful tips--these check lists will be reviewed with the counselor during the staff census meeting at least 1x per month
4. Counselors to discuss with clients on a daily/weekly basis when they have their individual sessions about the importance of their treatment plan--behavioral contracts to be implemented and signed by client when non-compliant for 1-2 weeks. Counselor to blue note that a behavioral contract has been made and signed and that contract attached to their chart. Also, making sure the record of service notes the non-compliance appropriately.
5. Discussions and plans to be made about client motivation between Executive Director and Clinical Director to help with compliance that include but not limited to positive re-enforcement, reward system, monthly client appreciation, etc.
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: 12/1/2022
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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 one of three applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicates a discharge summary be completed within seven days of discharge.
Client # 5 was admitted on December 9, 2021 and was discharged February 7, 2022. There was no documentation of a discharge summary in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To be in compliance with 709.9(a); there shall be a complete client record on an individual which includes information relative to the client's involvement with the project and this shall include, but not be limited to, the following: (10) Discharge summary.
Clinical Director had a meeting with all clinical staff and expressed the importance of making sure that a client's clinical chart is in full completion from start to finish. A discharge summary was added to the client record that was missing.
Continued staff meetings will be held on clinical documentation. Per office on weekly basis/all ABT staff on quarterly basis.
Clinical Director to audit client charts on a monthly basis to ensure this does not happen again.
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