INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on March 23, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pittsburg Recovery Center 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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709.24 (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.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to provide written procedures for the management of treatment/rehabilitation services for clients.
The Partial Hospitalization service procedure for progress notes does not address the time frame for completion. The procedure for treatment plan completion is not consistent; one procedure states the treatment plan will be completed by the 5th session, and one procedure states the treatment plan will be completed by the 6th session.
The Outpatient service procedure for progress notes does not address the time frame for completion. The procedure for record of service does not address who is responsible or the time frame of completion.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the October 12 - 13, 2022 annual licensing inspection.
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Plan of Correction
On 4/3/2023, counselor updated the Partial Hospitalization service procedure for progress notes to address the time frame for completion. The procedure for treatment plan completion was updated to be consistent throughout and states that the treatment plan will be completed by the 5th session. The outpatient service procedure was updated to include the time frame for completion of progress notes. The procedure for record of service was updated to address who is responsible and the time frame of completion. The facility director will review the procedures to ensure that all corrections have been made by 4/7/2023. |
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.
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Observations
Based on a review of client records and a discussion with facility staff, the facility failed to document the specific information to be disclosed on consent to release information forms in five of six applicable client records.
The release of information form for the funding source, failed to include the specific information to be disclosed, but disclosure was made.
Client #1 was admitted to partial hospitalization on March 6, 2023 and was discharged on March 21, 2023. A release of information form to the funding source was signed and dated by the client on March 6, 2023, but the release form failed to document the specific information to be disclosed.
Client # 2 was admitted to partial hospitalization on February 20, 2023 and was still active at the time of the inspection. A release of information form to the funding source was signed and dated by the client on February 20, 2023, but the release form failed to document the specific information to be disclosed.
Client # 4 was admitted to partial hospitalization on February 28, 2023 and was still active at the time of the inspection. A release of information form to the funding source was signed and dated by the client on February 28, 2023, but the release form failed to document the specific information to be disclosed.
Client # 5 was admitted to partial hospitalization on February 28, 2023 and was still active at the time of the inspection. A release of information form to the funding source was signed and dated by the client on February 28, 2023, but the release form failed to document the specific information to be disclosed.
Client #10 was admitted to partial hospitalization on February 6, 2023 and was discharged on February 13, 2023. A release of information form to the funding source was signed and dated by the client on February 6, 2023, but the release form failed to document the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/17/2023, counselor changed the release of information form for the funding source in the electronic charting system to include the specific information to be disclosed. This information includes: presence and progress in treatment; treatment plans; psychological history and assessment; results of physical exam; medical history/current status; biopsychosocial assessment; lab test results; employment information; aftercare recommendations and discharge planning. Clients #2, #4, #5, #10, and all current clients will sign the new ROI forms by 4/28/2023. Client #1 has since been discharged and is unavailable to sign the updated form. Moving forward, these updated forms will always be used for new client admissions. The facility director will monitor the client records to ensure that all proper ROI forms are used. |
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.
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Observations
Based on a review of client records, the facility failed to assure partial hospitalization clients are provided individual counseling services at least twice a week in four of four applicable client records.
Client # 2 was admitted to partial hospitalization on February 20, 2023 and was still active at the time of the inspection. The record of service and progress notes indicated only one individual counseling session occurred for the weeks of February 27, March 6, and March 13, 2023. Individual counseling services were not provided at least twice a week for client #2.
Client # 3 was admitted to partial hospitalization on February 8, 2023 and was still active at the time of the inspection. The record of service and progress notes indicated only one individual counseling session occurred for the weeks of February 13, 20, 27, March 3, 6, and March 13, 2023. Individual counseling services were not provided at least twice a week for client #3.
Client # 4 was admitted to partial hospitalization on February 28, 2023 and was still active at the time of the inspection. The record of service and progress notes indicated only one individual counseling session occurred for the weeks of March 6, and March 13, 2023. Individual counseling services were not provided at least twice a week for client #4.
Client # 5 was admitted to partial hospitalization on February 28, 2023 and was still active at the time of the inspection. The record of service and progress notes indicated only one individual counseling session occurred for the weeks of March 6, and March 13, 2023. Individual counseling services were not provided at least twice a week for client #5.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the October 12 - 13, 2022 annual licensing inspection.
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Plan of Correction
Master's level counselor will be responsible for conducting individual counseling services at least twice a week for PHP clients from 4/3/2023 and moving forward. The facility director will monitor the counselor to ensure that all required sessions are occurring weekly. |