INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 17, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Rosewood Recovery, LLC 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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709.28 (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.
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Observations
Based on a review of client records, the facility failed to document whether a copy of a client consent was offered to the client and a copy maintained in the client record in seven of seven records reviewed.
Client #1 was admitted on July 28, 2023 and was still a current client at the time of the inspection. Client #1 had informed and voluntary consents to disclose information signed by the client and dated July 28, 2023, for a family member, funder, third party billing service and a government office; there was no documentation whether a copy of the consents were offered to the client.
Client #2 was admitted on June 13, 2023 and was still a current client at the time of the inspection. Client #2 had informed and voluntary consents to disclose information signed by the client and dated June 13, 2023, for a family member, funder, third party billing service and a government office; there was no documentation whether a copy of the consents were offered to the client.
Client #3 was admitted on July 28, 2023 and was still a current client at the time of the inspection. Client #3 had informed and voluntary consents to disclose information signed by the client and dated July 28, 2023, for a family member, funder, third party billing service and a government office; there was no documentation whether a copy of the consents were offered to the client.
Client #4 was admitted on July 5, 2023 and was still a current client at the time of the inspection. Client #4 had informed and voluntary consents to disclose information signed by the client and dated July 5, 2023, for a family member, referral source, third party billing service and a government office; there was no documentation whether a copy of the consents were offered to the client.
Client #5 was admitted on June 13, 2023 and was still a current client at the time of the inspection. Client #5 had informed and voluntary consents to disclose information signed by the client and dated June 13, 2023, for a family member, funder, third party billing service and a government office; there was no documentation whether a copy of the consents were offered to the client.
Client #6 was admitted on August 1, 2023 and was still a current client at the time of the inspection. Client #6 had informed and voluntary consents to disclose information signed by the client and dated August 1, 2023, for a family member, funder, third party billing service, referral source and a government office; there was no documentation whether a copy of the consents were offered to the client.
Client #7 was admitted on June 9, 2023 and discharged on July 17, 2023. Client #7 had informed and voluntary consents to disclose information signed by the client and dated June 9, 2023, for a family member, funder, third party billing service, recovery house and a government office; there was no documentation whether a copy of the consents were offered to the client.
These findings were review with facility staff during the licensing process.
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Plan of Correction
On 8/17/2023 the Facility Director updated the consents so that it now contains a statement regarding if the client was offered a copy of the consent. This was applied to all consent templates. The Facility Director will monitor compliance with completing this portion of the consent through chart reviews and supervision. For clients admitted prior to 8/17/2023 they will be advised of their right to receive a copy of consents and this will be documented via attestation in their charts by 9/30/2023. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to have a complete client orientation to the project that included a familiarization with the hours of operation in seven of seven records reviewed.
Client #1 was admitted on July 28, 2023 and was still a current client at the time of the inspection. There was no documentation that client #1 ' s orientation to the project included the hours of operation.
Client #2 was admitted on June 13, 2023 and was still a current client at the time of the inspection. There was no documentation that client #2 ' s orientation to the project included a familiarization with the hours of operation.
Client #3 was admitted on July 28, 2023 and was still a current client at the time of the inspection. There was no documentation that client #3 ' s orientation to the project included a familiarization with the hours of operation.
Client #4 was admitted on July 5, 2023 and was still a current client at the time of the inspection. There was no documentation that client #4 ' s orientation to the project included a familiarization with the hours of operation.
Client #5 was admitted on June 13, 2023 and was still a current client at the time of the inspection. There was no documentation that client #5 ' s orientation to the project included the hours of operation.
Client #6 was admitted on August 1, 2023 and was still a current client at the time of the inspection. There was no documentation that client #6 ' s orientation to the project included the hours of operation.
Client #7 was admitted on June 9, 2023 and discharged on July 17, 2023. There was no documentation that client #7 ' s orientation to the project included the hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/18/2023 the Facility Director updated the client handbook to include hours of operation. The Facility Director will ensure all admissions after 8/18/2023 sign the attestation acknowledging receipt of the handbook during admission. This will be monitored through chart audits and supervision. Clients admitted prior to 8/18/2023 will receive the updated copy of the Client Handbook and will be asked to sign an attestation confirming receipt. This will be completed by 9/30/2023. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to have a complete client orientation to the project that included a familiarization with the fee schedule in seven of seven records reviewed.
Client #1 was admitted on July 28, 2023 and was still a current client at the time of the inspection. There was no documentation that client #1 ' s orientation to the project included a familiarization with the fee schedule.
Client #2 was admitted on June 13, 2023 and was still a current client at the time of the inspection. There was no documentation that client #2 ' s orientation to the project included a familiarization with the fee schedule.
Client #3 was admitted on July 28, 2023 and was still a current client at the time of the inspection. There was no documentation that client #3 ' s orientation to the project included a familiarization with the fee schedule.
Client #4 was admitted on July 5, 2023 and was still a current client at the time of the inspection. There was no documentation that client #4 ' s orientation to the project included a familiarization with the fee schedule.
Client #5 was admitted on June 13, 2023 and was still a current client at the time of the inspection. There was no documentation that client #5 ' s orientation to the project included the fee schedule.
Client #6 was admitted on August 1, 2023 and was still a current client at the time of the inspection. There was no documentation that client #6 ' s orientation to the project included the fee schedule.
Client #7 was admitted on June 9, 2023 and discharged on July 17, 2023. There was no documentation that client #7 ' s orientation to the project included the fee schedule.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/18/2023 the Facility Director updated the client handbook to include the program fee schedule. The Facility Director will ensure all admissions after 8/18/2023 sign the attestation acknowledging receipt of the handbook during admission. This will be monitored through chart audits and supervision. Clients admitted prior to 8/18/2023 will receive the updated copy of the Client Handbook and will be asked to sign an attestation confirming receipt. This will be completed by 9/30/2023. |
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 review and update treatment and rehabilitation at least every 60 days in two of two applicable records reviewed.
Client #2 was admitted on June 13, 2023 and was still a current client at the time of the inspection. Client #2 had a treatment and rehabilitation plan developed on June 13, 2023, and the update was due no later than August 13, 2023; however, it was not documented until August 15, 2023.
Client #5 was admitted on June 13, 2023 and was still a current client at the time of the inspection. Client #5 had a treatment and rehabilitation plan developed on June 13, 2023, and the update was due no later than August 13, 2023; however, it was not documented until August 17, 2023.
These findings were review with facility staff during the licensing process.
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Plan of Correction
Effective 8/18/2023 all current clinical staff were reminded of the regulations regarding treatment plan updates including time frame for updates and that the client does not need to be present. As clinical staff are hired this will be a part of the orientation and training. Treatment plans due on and after 8/18/2023 will be updated and documented following the regulations. |
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 client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in three out of seven records reviewed.
Client #1 was admitted on July 28, 2023 and was still a current client at the time of the inspection. Client #1 had a treatment and rehabilitation plan dated July 28, 2023, that indicated one group session would occur weekly. There was no documentation in the record of group sessions occurring.
Client #3 was admitted on July 28, 2023 and was still a current client at the time of the inspection. Client #3 had a treatment and rehabilitation plan dated July 28, 2023, that indicated one group session would occur weekly. There was no documentation in the record of group sessions occurring.
Client #6 was admitted on August 1, 2023 and was still a current client at the time of the inspection. Client #6 had a treatment and rehabilitation plan dated August 1, 2023, that indicated one group session would occur weekly. There was no documentation in the record of group sessions occurring.
These findings were review with facility staff during the licensing process.
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Plan of Correction
Effective 8/18/2023 all current clinical staff were reminded to write treatment plans to the individual and ensure that they are receiving the services as specified in the treatment or documenting reasons why those services are not occurring. As clinical staff are hired this will be a part of the orientation and training. |