INITIAL COMMENTS
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This report is a result of an off-site complaint investigation conducted on April 30, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the off-site complaint investigation, Holcomb Associates, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 the client chart, the facility failed to include the reason for termination in the written notification of the decision to involuntarily terminate a client's treatment.
Client # 1 was admitted on March 6, 2025, and discharged on March 26, 2025. The Discharge/Re-Engagement Letter, dated March 20, 2025, did not indicate the reason for an administrative discharge.
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Plan of Correction
Staff training will be conducted by the Clinical Coordinator on 5/8/25 to instruct staff on including specific reasons on all administrative discharge letters. Moving forward, all administrative discharges will be routed to the Clinical Coordinator before they go out so she can verify that this information is included on the discharge letter. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of the client chart and facility policy 28.22, the facility failed to provide an opportunity to request reconsideration of a decision terminating treatment.
Facility policy 28.22 indicates the client will have an opportunity to request reconsideration of a decision to terminate treatment, in writing, to the Project Director within 30 days of the notification. The client will be informed of this right in the termination notice.
Client # 1 was admitted on March 6, 2025, and discharged on March 26, 2025. The Discharge/Re-Engagement Letter, dated March 20, 2025, did not indicate how to request reconsideration of the decision to terminate treatment.
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Plan of Correction
Holcomb will work with the Evolv and clinical teams to add wording to our discharge letter that explains how to request reconsideration of a decision to terminate treatment within 30 days of the notification. The Clinical Coordinator will ensure compliance with her team. This will be completed by 6/14/25. |