INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 15-17, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Oil Region Recovery, Inc. 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 administrative information, the facility failed to document a policy and procedure for notifying the emergency contact for clients who discharge against facility advice in the inpatient non-hospital short term detoxification level of care.
Client #14 was admitted to the detoxification level of care on February 26, 2024, and discharged against facility advice on March 2, 2024. There was no documentation of an attempt to contact the emergency contact.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Director has trained staff on the procedure for phoning emergency contact after a client leaves treatment AFA/ASR. This will be documented in the client record under the correspondence tab and followed by the Tech Supervisor. Policy and Procedure manual will be updated to include notification of emergency contact when clients leave detox AFA. |
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.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to voluntarily terminate the client's treatment at the project in one of one applicable record.
Client #11 was admitted to the detoxification level of care on January 03, 2024, and discharged on January 7, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Staff was trained by the Clinical Director on how to fill out and file documents for clients leaving treatment. Each client leaving treatment AMA/ASR will be given a written notice of their termination of treatment. This will be filed in the client chart with Admit paperwork. This will be monitored by the Clinical Director |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of residential client records, the facility failed to notify the emergency contact of a client's decision to leave against facility advice in one of one applicable record.
The facility's inpatient non-hospital residential policy and procedure manual states the client's emergency contact will be notified within 12 hours of the client's decision to leave against facility advice, providing there is consent given in writing for Oil Region Recovery, Inc to contact the emergency contact.
Client #6 was admitted to the residential level of care on February 29, 2024, and discharged against facility advice on April 01, 2024.
There was a consent for the emergency contact in client #6 ' s record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Director met with staff on 5/16 and trained them on the procedure for notifying emergency contacts with in 12 hours of a client leaving AFA. Staff will document the phone call on the correspondence page in the client record. This will be monitored by the Clinical Director. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of residential client records, the facility failed to document follow-up information in two of three discharged records.
The facility's policy and procedure manual states follow-up contact is to be completed for all discharges within seven days.
There was no follow-up information documented in client records #6 and #7.
Client #6 was admitted to the residential level of care on February 29, 2024, and was discharged on April 01, 2024.
Client #7 was admitted to the residential level of care on February 09, 2024, and was discharged on March 01, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Staff were trained on 5/16/24 on the process for completing follow up calls and where the document is to be filed after the call is made. Process involves counselor providing the document to admin asst and she makes the call and then the document is filed in the client chart. The Clinical Director will follow the compliance with the POC |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of outpatient client records, the facility failed to document follow-up information in three of four discharged records.
The facility's policy and procedure manual states follow-up contact is to be completed for all discharges within 7 days.
There was no follow-up information documented in client records #19, 20 and 21.
Client #19 was admitted to the outpatient level of care on December 28, 2023, and discharged on March 21, 2024.
Client #20 was admitted to the outpatient level of care on December 21, 2023, and discharged on March 22, 2024.
Client #21 was admitted to the outpatient level of care on December 22, 2023, and discharged on February 15, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
on 5/16/24 OP counselor was trained for process for doing the follow up calls for clients. All clients that are DC will have a follow up call within 7 days of being DC from treatment. This will be documented in the client file. This will be monitored by the clinical Director for compliance |