INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring inspection conducted on February 21, 2024 through February 22, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wilkes-Barre Treatment LLC dba Clearbrook Treatment Centers 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in ten of fourteen applicable client records reviewed.
The facility policy and procedure manual stated the individual treatment and rehabilitation plan is to be completed within five days of admission.
Client # 16 was admitted to the partial hospitalization activity on February 6, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by February 11, 2024; however, the plan was not completed at the time of the inspection.
Client # 17 was admitted to the partial hospitalization activity on February 6, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by February 11, 2024; however, the plan was not completed until February 14, 2024.
Client # 18 was admitted to the partial hospitalization activity on August 30, 2023 and was discharged on September 26, 2023. The individual treatment and rehabilitation plan was due to be completed by September 4, 2023; however, the plan was not completed until September 12, 2023.
Client # 20 was admitted to the partial hospitalization activity on August 24, 2023 and was discharged on October 3, 2023. The individual treatment and rehabilitation plan was due to be completed by August 29, 2023; however, the plan was not completed until September 5, 2023.
Client # 21 was admitted to the partial hospitalization activity on April 10, 2023 and was discharged on May 14, 2023. The individual treatment and rehabilitation plan was due to be completed by April 15, 2023; however, the plan was not completed until April 17, 2023.
Client # 22 was admitted to the outpatient activity on May 15, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by May 20, 2023; however, the plan was not completed until May 31, 2023.
Client # 23 was admitted to the outpatient activity on October 4, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by October 9, 2023; however, the plan was not completed until October 19, 2023.
Client # 24 was admitted to the outpatient activity on October 3, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by October 8, 2023; however, the plan was not completed until October 11, 2023.
Client # 25 was admitted to the outpatient activity on May 31, 2023 and was discharged on June 28, 2023. The individual treatment and rehabilitation plan was due to be completed by June 5, 2023; however, the plan was not completed until June 28, 2023.
Client # 27 was admitted to the outpatient activity on August 10, 2023 and was discharged on August 23, 2023. The individual treatment and rehabilitation plan was due to be completed by August 15, 2023; however, the plan was not completed until August 17, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On February 27, 2024, the Clinical Director and Clinical Supervisor organized a refresher training session for Therapists, focusing on the completion of the master treatment plan within a five-day timeframe. The Compliance & Quality team has developed a mechanism for Quantitative Doc Surveillance that monitors compliance with timeframes, this report is provided to the Clinical Director daily and reviewed in the aggregate monthly. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to document the specific information to be released on consent to release information forms in ten of twenty-eight client records reviewed.
Client #1 was admitted to the inpatient non-hospital detoxification activity on January 11, 2024 and was discharged on January 12, 2024. A release of information form to the funding source was signed and dated by the client on January 11, 2024; however, the specific information to be disclosed was not included on the form.
Client #2 was admitted to the inpatient non-hospital detoxification activity on January 14, 2024 and was discharged on January 19, 2024. A release of information form to the funding source was signed and dated by the client on January 14, 2024; however, the specific information to be disclosed was not included on the form.
Client #5 was admitted to the inpatient non-hospital detoxification activity on January 24, 2024 and was discharged on January 27, 2024. A release of information form to the funding source was signed and dated by the client on January 27, 2024; however, the specific information to be disclosed was not included on the form.
Client #6 was admitted to the inpatient non-hospital detoxification activity on January 17, 2024 and was discharged on January 25, 2024. A release of information form to the funding source was signed and dated by the client on January 25, 2024; however, the specific information to be disclosed was not included on the form.
Client #8 was admitted to the inpatient non-hospital activity on January 13, 2024 and was discharged on January 16, 2024. A release of information form to the funding source was signed and dated by the client on January 11, 2024; however, the specific information to be disclosed was not included on the form.
Client #9 was admitted to the inpatient non-hospital activity on January 20, 2024 and was discharged on February 13, 2024. A release of information form to the funding source was signed and dated by the client on January 14, 2024; however, the specific information to be disclosed was not included on the form.
Client #12 was admitted to the inpatient non-hospital activity on January 28, 2024 and was discharged on February 14, 2024. A release of information form to the funding source was signed and dated by the client on January 27, 2024; however, the specific information to be disclosed was not included on the form.
Client #15 was admitted to the partial hospitalization activity on January 2, 2024 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on January 2, 2024; however, the specific information to be disclosed was not included on the form.
Client #16 was admitted to the partial hospitalization activity on February 6, 2024 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on February 6, 2024; however, the specific information to be disclosed was not included on the form.
Client #17 was admitted to the partial hospitalization activity on February 6, 2024 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on February 6, 2024; however, the specific information to be disclosed was not included on the form.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The consent form for releasing information has been revised to specify the entity and the exact details of information that can be disclosed. The Director of Operations organized a refresher training session for intake coordinators to ensure they thoroughly review consents, ensuring that all necessary information is included when signing them with clients upon admission. |
709.28 (c) (6) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
|
Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent to release information form will expire in ten of twenty-eight client records reviewed.
Client #1 was admitted to the inpatient non-hospital detoxification activity on January 11, 2024 and was discharged on January 12, 2024. A release of information form to the funding source was signed and dated by the client on January 11, 2024; however, the date, event, or condition upon which the consent will expire was not included on the form.
Client #2 was admitted to the inpatient non-hospital detoxification activity on January 14, 2024 and was discharged on January 19, 2024. A release of information form to the funding source was signed and dated by the client on January 14, 2024; however, the date, event, or condition upon which the consent will expire was not included on the form.
Client #5 was admitted to the inpatient non-hospital detoxification activity on January 24, 2024 and was discharged on January 27, 2024. A release of information form to the funding source was signed and dated by the client on January 27, 2024; however, the date, event, or condition upon which the consent will expire was not included on the form.
Client #6 was admitted to the inpatient non-hospital detoxification activity on January 17, 2024 and was discharged on January 25, 2024. A release of information form to the funding source was signed and dated by the client on January 25, 2024; however, the date, event, or condition upon which the consent will expire was not included on the form.
Client #8 was admitted to the inpatient non-hospital activity on January 13, 2024 and was discharged on January 16, 2024. A release of information form to the funding source was signed and dated by the client on January 11, 2024; however, the date, event, or condition upon which the consent will expire was not included on the form.
Client #9 was admitted to the inpatient non-hospital activity on January 20, 2024 and was discharged on February 13, 2024. A release of information form to the funding source was signed and dated by the client on January 14, 2024; however, the date, event, or condition upon which the consent will expire was not included on the form.
Client #12 was admitted to the inpatient non-hospital activity on January 28, 2024 and was discharged on February 14, 2024. A release of information form to the funding source was signed and dated by the client on January 27, 2024; however, the date, event, or condition upon which the consent will expire was not included on the form.
Client #15 was admitted to the partial hospitalization activity on January 2, 2024 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on January 2, 2024; however, the date, event, or condition upon which the consent will expire was not included on the form.
Client #16 was admitted to the partial hospitalization activity on February 6, 2024 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on February 6, 2024; however, the date, event, or condition upon which the consent will expire was not included on the form.
Client #17 was admitted to the partial hospitalization activity on February 6, 2024 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on February 6, 2024; however, the date, event, or condition upon which the consent will expire was not included on the form.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The release of information consent form has been updated to incorporate the date, event, and expiration date indicating when the form becomes invalid. The Director of Operations organized a refresher training session for intake coordinators to ensure they thoroughly review consents, ensuring that all necessary information is included when signing them with clients upon admission |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent to release information form was offered to the client in twenty-eight of twenty-eight client records reviewed.
In every client record reviewed, there were two hospital consent forms and there was no documentation that a copy of the forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On February 27th, 2024, the Compliance & Quality department revised the Geisinger Hospital & General Hospital consent forms to document that clients were provided with the option to receive a copy of the consent. The Director of Operations organized a refresher training session for intake coordinators to ensure they thoroughly reviewed consent forms and that the client was offered a copy of each consent form. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
|
Observations
Based on a review of client records, the facility failed to assure clients admitted to the partial hospitalization program received individual counseling services at least twice a week in four of seven applicable client records reviewed.
Client # 15 was admitted to the partial hospitalization activity on January 2, 2024 and was still active at the time of the inspection. The record of service and progress notes indicated that individual counseling sessions occurred once a week, rather than twice a week, during the week of January 7, 2024 through January 13, 2024.
Client # 18 was admitted to the partial hospitalization activity on August 30, 2023 and was discharged on September 26, 2023. The record of service and progress notes indicated that individual counseling sessions occurred once a week, rather than twice a week, during the weeks of September 3, 2023 through September 23, 2023.
Client # 19 was admitted to the partial hospitalization activity on December 7, 2023 and was discharged on February 14, 2024. The record of service and progress notes indicated that individual counseling sessions occurred once a week, rather than twice a week, during the weeks of December 10, 2023 through January 13, 2024.
Client # 20 was admitted to the partial hospitalization activity on August 24, 2023 and was discharged on October 3, 2023. The record of service and progress notes indicated that individual counseling sessions occurred once a week, rather than twice a week, during the weeks of September 3, 2023 through September 23, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On February 26, 2024, The Clinical Director and Clinical Supervisor coordinated a refresher training session for Outpatient Therapists, emphasizing the completion of individual sessions twice weekly. Additionally, the facility performs monthly internal chart audits and convenes monthly to analyze any emerging trends. An additional audit has been implemented to verify the completion of two individual sessions per week. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
|
Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for maintenance or detoxification treatment in thirteen of fifteen applicable patient records reviewed.
Patient #1 was admitted to the inpatient non-hospital detoxification activity on January 11, 2024 and was discharged on January 12, 2024. The physician first prescribed maintenance medication to the patient on January 12, 2024. There was no documentation of an informed, voluntary, written consent before an agent was administered in the record at the time of the inspection.
Patient #2 was admitted to the inpatient non-hospital detoxification activity on January 14, 2024 and was discharged on January 19, 2024. The physician first prescribed maintenance medication to the patient on January 15, 2024. There was no documentation of an informed, voluntary, written consent before an agent was administered in the record at the time of the inspection.
Patient #3 was admitted to the inpatient non-hospital detoxification activity on August 9, 2023 and was discharged on August 15, 2023. The physician first prescribed maintenance medication to the patient on August 11, 2023. There was no documentation of an informed, voluntary, written consent before an agent was administered in the record at the time of the inspection.
Patient #4 was admitted to the inpatient non-hospital detoxification activity on August 15, 2023 and was discharged on August 26, 2023. The physician first prescribed maintenance medication to the patient on August 22, 2023. There was no documentation of an informed, voluntary, written consent before an agent was administered in the record at the time of the inspection.
Patient #5 was admitted to the inpatient non-hospital detoxification activity on January 24, 2024 and was discharged on January 27, 2024. The physician first prescribed maintenance medication to the patient on January 25, 2024. The informed, voluntary, written consent to treat with an agent was signed by the patient on January 30, 2024, after the initial dose.
Patient #6 was admitted to the inpatient non-hospital detoxification activity on January 17, 2024 and was discharged on January 25, 2024. The physician first prescribed maintenance medication to the patient on January 25, 2024. The informed, voluntary, written consent to treat with an agent was signed by the patient on January 30, 2024, after the initial dose.
Patient #7 was admitted to the inpatient non-hospital detoxification activity on July 17, 2023 and was discharged on July 21, 2023. There was no documentation of an informed, voluntary, written consent before an agent was administered in the record at the time of the inspection.
Patient #8 was admitted to the inpatient non-hospital activity on January 13, 2024 and was discharged on January 16, 2024. The physician first prescribed maintenance medication to the patient on January 12, 2024. There was no documentation of an informed, voluntary, written consent before an agent was administered in the record at the time of the inspection.
Patient #9 was admitted to the inpatient non-hospital activity on January 20, 2024 and was discharged on February 13, 2024. The physician first prescribed maintenance medication to the patient on January 15, 2024. There was no documentation of an informed, voluntary, written consent before an agent was administered in the record at the time of the inspection.
Patient #10 was admitted to the inpatient non-hospital activity on August 16, 2024 and was discharged on August 21, 2024. The physician first prescribed maintenance medication to the patient on August 11, 2024. There was no documentation of an informed, voluntary, written consent before an agent was administered in the record at the time of the inspection.
Patient #11 was admitted to the inpatient non-hospital activity on August 27, 2023 and was discharged on October 2, 2023. The physician first prescribed maintenance medication to the patient on August 22, 2023. There was no documentation of an informed, voluntary, written consent before an agent was administered in the record at the time of the inspection.
Patient #12 was admitted to the inpatient non-hospital activity on January 28, 2024 and was discharged on February 14, 2024. The physician first prescribed maintenance medication to the patient on January 25, 2024. The informed, voluntary, written consent to treat with an agent was signed by the patient on January 30, 2024, after the initial dose.
Patient #15 was admitted to the partial hospitalization activity on January 2, 2024 and was still active at the time of the inspection. There was no documentation of an informed, voluntary, written consent before an agent was administered in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On February 27th, 2024, the Medical Director and Director of Nursing held a training session for the nursing staff. The purpose was to ensure that upon admission, all Methadone Maintenance clients receive and sign the informed consent for Methadone. Additionally, audits of these informed consents are now part of the bi-weekly chart audits conducted by the Compliance & Quality team. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
|
Observations
Based on a review of patient records, the facility failed to complete an initial drug-screening analysis for each prospective patient and a random urinalysis at least monthly thereafter in two of fifteen applicable patient records reviewed.
Patient #11 was admitted to the inpatient non-hospital activity on August 27, 2023 and was discharged on October 2, 2023. There was no monthly urinalysis documented in the record for the month of September 2023.
Patient #15 was admitted to the partial hospitalization activity on January 2, 2024 and was still active at the time of the inspection. The initial drug-screening urinalysis was completed on January 11, 2024; however, the initial dose was given to the patient on January 3, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On February 29, 2024, the Director of Nursing held a training session for the nursing staff to familiarize them with the mandate, stating that NTP clients are required to undergo monthly random urinalysis testing. Additionally, the Director of Nursing introduced a refresher training course emphasizing the significance of accurately documenting the initial urinalysis results in the medical record. The Compliance & Quality team generates monthly chart audit reports and bi-weekly discrepancy reports, which are then reviewed and addressed within a specified timeframe by Clinical leadership. This systematic process ensures our compliance with properly documenting urinalysis results. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files, which includes admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, to another narcotic treatment program in two of two applicable patient records reviewed.
Patient #8 was admitted to the inpatient non-hospital activity on January 13, 2024 and was transferred to another narcotic treatment program on January 16, 2024. The record did not include documentation that the receiving narcotic treatment program was notified of the date of admission of the patient, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient.
Patient #9 was admitted to the inpatient non-hospital activity on January 20, 2024 and was transferred to another narcotic treatment program on February 13, 2024. The record did not include documentation that the receiving narcotic treatment program was notified of the date of admission of the patient, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A new protocol has been introduced regarding the transfer documentation upon discharge. Collaboratively developed by the case manager supervisor and the director of nursing, this new procedure requires that upon the client's discharge, particularly those undergoing medication-assisted treatment (MAT), the assigned case manager ensures the submission of comprehensive documentation. This documentation will encompass the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summaries, exception requests, and the current patient status to the narcotic treatment program to which the client is transferring. Subsequently, the case manager will upload the scanned documentation and all relevant correspondence to the client's medical record. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in five of five applicable patient records reviewed.
Patient #1 was transferred into the inpatient non-hospital detoxification activity from another narcotic treatment program on January 11, 2024 and was discharged on January 12, 2024. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #2 was admitted to the inpatient non-hospital detoxification activity from another narcotic treatment program on January 14, 2024 and was discharged on January 19, 2024. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #3 was admitted to the inpatient non-hospital detoxification activity from another narcotic treatment program on August 9, 2023 and was discharged on August 15, 2023. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #5 was admitted to the inpatient non-hospital detoxification activity from another narcotic treatment program on January 24, 2024 and was discharged on January 27, 2024. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #6 was admitted to the inpatient non-hospital detoxification activity from another narcotic treatment program on January 17, 2024 and was discharged on January 25, 2024. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A new protocol has been implemented concerning the documentation of client admission notification and the administration of their initial dosage. When requesting dosing history from the former NTP (Narcotic Treatment Program), nursing staff will notify them of the date that the client has been admitted and the date and time that the client received their initial dose. Subsequently, the nurse will document the transfer of this information in a PRN note and upload all correspondence to the client's medical record |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every fifteen days for clients in short-term inpatient treatment in three of three applicable client records reviewed.
Client #9 was admitted to the inpatient non-hospital activity on January 20, 2024 and was discharged on February 13, 2024. The individual treatment and rehabilitation plan was completed on January 23, 2024, and the first update was due no later than February 7, 2024; however, the update was not completed at the time of inspection.
Client #11 was admitted to the inpatient non-hospital activity on August 27, 2023 and was discharged on October 2, 2023. A treatment plan update was completed on September 13, 2023, and the next update was due no later than September 28, 2023; however, the update was not completed prior to discharge.
Client #14 was admitted to the inpatient non-hospital activity on October 23, 2023 and was discharged on December 6, 2023. A treatment plan update was completed on October 26, 2023, and the next update was due no later than November 10, 2023; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On February 27th, 2024, the Clinical Director and Clinical Supervisor met with the therapists to discuss the importance and reasoning behind the treatment plan, emphasizing the need for it to be reviewed and updated at least every 15 days. The Compliance & Quality team has developed a mechanism for Quantitative Documentation Surveillance that monitors compliance with timeframes; this report is provided to the Clinical Director daily and reviewed in the aggregate monthly. |
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.
|
Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days for clients in outpatient treatment in three of four applicable client records reviewed.
Client # 22 was admitted to the outpatient activity on May 15, 2023 and was still active at the time of the inspection. A treatment plan update was completed on August 21, 2023 and the next update was due no later than October 21, 2023; however, the update was completed on November 13, 2023.
Client # 24 was admitted to the outpatient activity on October 3, 2023 and was still active at the time of the inspection. A treatment plan update was completed on November 17, 2023 and the next update was due no later than January 17, 2024; however, the update was completed on February 15, 2024.
Client # 28 was admitted to the outpatient activity on August 15, 2023 and was discharged on January 25, 2024. The individual treatment and rehabilitation plan was completed on August 21, 2023 and the first update was due no later than October 21, 2023; however, the update was completed on November 21, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On February 27th, 2024, the Clinical Director and Clinical Supervisor convened with the therapists to discuss the significance and rationale of the treatment plan updates that must be completed every 60 days. The Clinical Director and Clinical Supervisor will monitor the census, which will preempt any oversights in conducting these vital reviews for clients approaching the 60-day mark. The Compliance & Quality team has developed a mechanism for Quantitative Doc Surviellance that monitors compliance with timeframes, this report is provided to the Clinical Director daily and reviewed in the aggregate monthly. |