D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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CONEWAGO PLACE
424 NYE ROAD
HUMMELSTOWN, PA 17036

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Survey conducted on 07/30/2013

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on July 29-30, 2013 by staff from the Program Licensure Division. Based on the findings of the on-site inspection, Conewago Place 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
709.33(a) LICENSURE Notification of Termination 709.33. Notification of termination. (a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
Observations Based on a review of client records, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one client records. The findings include: One client record which required documentation of written notification to the client informing him/her of the decision to terminate the client's treatment was reviewed on July 30, 2013. The facility failed to document notification to the client in record #11. Client # 11 was admitted on 3/5/13 and discharged on 4/2/13 due to non-compliance with treatment. This client record did not include documentation from the facility of the written notification to terminate this client's treatment at the project. The Compliance Officer and Project Director confirmed the findings.	Plan of Correction The Corporate Clinical Director retrained all Clinical Staff on 8/14/13 on the appropriate completion of the facilities involuntary termination process; specifically focusing on written notification of termination of services prior to discharge. The Facility Clinical Director will monitor appropriate completion during weekly client chart reviews beginning 8/16/13. The Corporate Compliance Officer will monitor appropriate completion beginning 8/30/13 to ensure on-going compliance.
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 document in the treatment plan update the client's progress as it relates to the goals stated on the comprehensive treatment plan in seven of ten records. The findings include: Ten client records which required treatment plan updates and documentation of the client's progress as it related to the goals on the treatment plan were reviewed July 29-30, 2013. The facility failed to document progress as it related to the goals stated on the treatment plan for clients # 2, 3, 4, 5, 6, 7, and 9. Client # 2 was admitted on 6/17/13 and was still an active client at the time of the inspection. A treatment plan update was completed on 7/8/13 and did not include documentation of progress on stated goals and objectives but instead included the following generalized terms; in progress or completed. Problem 1: Objectives 1 and 3 stated "completed" and Objective 2 "in progress". Problem 2: Objective 1 stated "completed" and Objectives 2, 3, and 4 "in progress". Problem 3: Objective 1 stated "completed" and Objective 2 "in progress". Problem 4: Objective 1 stated "completed" and Objectives 2, 3, and 4 "in progress". Client # 3 was admitted on 5/28/13 and was still an active client at the time of the inspection. Treatment plan updates were completed on 6/18/13 and 7/17/13 and did not include documentation of progress on stated goals and objectives but instead included the following generalized terms; in progress or completed. Treatment plan update on 6/18/13; Problem 1: Objectives 1, 2, 3, and 4 stated "completed". Problem 2: Objectives 1, 2, 3, and 4 stated "completed". Problem 4: Objectives 1, 2, 3, and 4 stated "in progress". Treatment plan update on 7/17/13; Problem 1: Objectives 1, 2, 3, and 4 stated "completed". Problem 2: Objectives 1, 2, 3, and 4 stated "completed". Problem 4: Objectives 1, 2, 3, and 4 stated "in progress". Problem 5: Objectives 1 and 2 stated "in progress". Client # 4 was admitted on 6/19/13 and was still an active client at the time of the inspection. A treatment plan update was completed on 7/9/13 and did not include documentation of progress on stated goals and objectives but instead included the following generalized terms; in progress or completed. Problem 5: Objectives 1 and 2 stated "completed". Problem 6: Objective 2, 3, 4, 6, 7, 8, and 9 stated "in progress". Client # 5 was admitted on 6/13/13 and was still an active client at the time of the inspection. A treatment plan update was completed on 7/3/13 and did not include documentation of progress on stated goals and objectives but instead included the following generalized terms; in progress or completed. Problem 1: Objectives 1 and 2 stated "completed". Problem 2: Objective 1 stated "completed". Problem 4: Objective 2 stated "in progress". Client # 6 was admitted on 6/11/13 and was still an active client at the time of the inspection. A treatment plan update was completed on 7/2/13 and did not include documentation of progress on stated goals and objectives but instead included the following generalized terms; in progress or completed. Problem 1: Objectives 1 and 3 stated "completed". Problem 2: Objective 1 stated "completed" and Objectives 2, 3, 4, 5, 6, and 7 "in progress". Problem 3: Objectives 1, 2, 3, 4, 5, and 6 stated "in progress". Client # 7 was admitted on 6/28/13 and was still an active client at the time of the inspection. A treatment plan update was completed on 7/22/13 and did not include documentation of progress on stated goals and objectives but instead included the following generalized terms; in progress or completed. Problem 1: Objectives 1, 2, 3, 4 and 5 stated "in progress". Problem 2: Objectives 1, 2, and 3 stated "in progress". Problem 3: Objectives 1, 2, 3, 4, 5, and 6 stated "completed". Problem 4: Objectives 1, 2, 3, and 4 stated "completed". Client # 9 was admitted on 7/1/13 and was still an active client at the time of the inspection. A treatment plan update was completed on 7/27/13 and did not include documentation of progress on stated goals and objectives but instead included the following generalized terms; in progress or completed. Problem 1: Objectives 1, 2, and 3 stated "completed" and Objectives 5, 6, and 7 "in progress". Problem 2: Objective 1 stated "completed" and Objectives 2, 3, 4, and 5" in progress". Problem 3: Objectives 1 and 2 stated "completed". Problem 4: Objectives 1 and 4 stated "completed" and Objectives 2, 3, 5 and 6 "in progress". The Compliance Officer and Project Director confirmed the findings.	Plan of Correction The Corporate Clinical Director retrained all Clinical Staff on the appropriate completion of the facilities treatment planning documentation on 8/14/13; specifically focusing on documentation of client progress on treatment planning goals. An addendum to the each of the identified deficient client goals has been added to the file to relect/outline the specific progress on the specific treatment plans. The Facility Clinical Director will monitor the appropriate completion of the facilities treatment planning process, on a weekly basis, beginning 8/16/13. The Corporate Compliance Officer will monitor appropriate completion of the facilities treatment planning process, on a monthly basis, beginning 8/30/13, to ensure on-going compliance.