INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 27, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Little Creek Outpatient Services LLC. was found not 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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709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
The facility failed to include documentation of a preliminary treatment plan during the intake and admission period for the partial hospitalization level of care in three of six client records reviewed.
Client #1 was admitted on June 3, 2019 and was discharged on July 8, 2019.
Client #5 was admitted on June 20, 2019 and was still active at the time of the inspection.
Client #6 was admitted on June 17, 2019 and was discharged on July 3, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During a clinical team meeting on 9/30/19, Clinical Director reviewed with clinical team standard 709.51 (b)(7) regarding preliminary treatment and rehabilitation plan as part of the intake and admission process. All clinical team members were also shown Little Creek's policy around treatment planning and time frames.
Clinical team members were given copies of the State Standard and Little Creek Policy, and signed off upon receipt. They will send preliminary/initial treatment plans to the Clinical Director to review and sign off on upon completion. This occurs within the EMR system and is time-stamped. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
The facility failed to develop an individual treatment and rehabilitation plan with the client while the client was in the partial hospitalization level of care in three of six client records reviewed.
Client #1 was admitted on June 3, 2019 and was discharged on July 8, 2019.
Client #5 was admitted on June 20, 2019 and was still active at the time of the inspection.
Client #6 was admitted on June 17, 2019 and was discharged on July 3, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During a clinical team meeting on 9/30/19, Clinical Director reviewed with clinical team standard 709.82 treatment and rehabilitation services. All clinical team members were also shown Little Creek's policy around treatment planning; including time frames, what is to be included, and how plans are documented.
Clinical team members were given copies of the State Standard and Little Creek Policy, and signed off upon receipt. They will send preliminary/initial treatment plans to the Clinical Director to review and sign off on upon completion. This occurs within the EMR system and is time-stamped. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
The facility failed to provide treatment plan updates within the regulatory timeframe for the partial hospitalization level of care in two of six client records reviewed.
Client #2 was admitted on June 7, 2019 and was discharged on July 13, 2019. The comprehensive treatment plan was completed on June 11, 2019 and the first update was due no later than July 11, 2019; however, the update was not completed prior to discharge.
Client #3 was admitted on July 15, 2019 and was discharged on August 14, 2019. The comprehensive treatment plan was completed on July 15, 2019 and the first update was due no later than August 15, 2019; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During a clinical team meeting on 9/30/19, Clinical Director reviewed with clinical team standard 709.82 (b) regarding treatment and rehabilitation plan reviews. Previously, the Clinical Director and thus, the treatment team, were operating under the premise that clients had to be present to participate in the treatment plan reviews. Team reviewed State standard together as well as Little Creek's policy around treatment planning and reviews, and all were made aware review must be completed within
Clinical team members were given copies of the State Standard and Little Creek Policy, and signed off upon receipt.
They will send reviews to the Clinical Director to review and sign off on upon completion. This occurs within the EMR system and is time-stamped. |
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
The facility failed to provide treatment plan updates within the regulatory timeframe for the outpatient level of care in five of seven client records reviewed.
Client #1 was admitted on February 11, 2019 and was active at the time of the inspection. The comprehensive treatment plan was completed on February 28, 2019 and the first update was due to be completed no later than April 28, 2019; however, the update was not completed until May 17, 2019.
Client #3 was admitted on January 25, 2019 and was active at the time of the inspection. A treatment plan update was due to be completed no later than June 28, 2019; however, the update was not completed until September 11, 2019.
Client #6 was admitted on October 12, 2018 and was active at the time of the inspection. A treatment plan update was due to be completed no later than August 30, 2019; however, the update was not completed until September 27, 2019.
Client #7 was admitted on April 18, 2019 and was active at the time of the inspection. The comprehensive treatment plan was completed on April 27, 2019 and the first update was due to be completed no later than June 27, 2019; however, there was no update completed as of the date of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
During a clinical team meeting on 9/30/19, Clinical Director reviewed with clinical team standard 709.82 (b) regarding treatment and rehabilitation plan reviews. Previously, the Clinical Director and thus, the treatment team, were operating under the premise that clients had to be present to participate in the treatment plan reviews. Team reviewed State standard together as well as Little Creek's policy around treatment planning and reviews, and all were made aware review must be completed within
Clinical team members were given copies of the State Standard and Little Creek Policy, and signed off upon receipt. They will send reviews to the Clinical Director to review and sign off on upon completion. This occurs within the EMR system and is time-stamped. |