INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 26, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Spark Wellness Elkins Park 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
|
709.24 (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.
|
Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in four of seven client records reviewed.
The policy and procedure manual stated that preliminary treatment plans are to be completed upon a client's admission.
Client # 1 was admitted on August 20, 2024 and was active at the time of inspection. The preliminary treatment plan was due to be completed no later than August 20, 2024; however, the plan was completed on August 28, 2024.
Client # 2 was admitted on October 4, 2024 and was active at the time of inspection. The preliminary treatment plan was due to be completed no later than October 4, 2024; however, the plan was completed on October 17, 2024.
Client # 3 was admitted on September 3, 2024 and was active at the time of inspection. The preliminary treatment plan was due to be completed no later than September 3, 2024; however, the plan was completed on September 9, 2024.
Client # 4 was admitted on July 1, 2024 and was discharged on September 13, 2024. The preliminary treatment plan was due to be completed no later than July 1, 2024; however, the plan was completed on July 10, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Director will reinforce with staff that the preliminary treatment plan is to be due at admission and is to be included in the consents for admission so that it is always included. Per the intake process an email is sent by the clinician once the intake is completed to the clinical director. The clinical director will then go into the EMR and make sure the treatment plan is signed and correctly completed. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of four applicable client records reviewed.
Client # 1 was admitted on August 20, 2024 and was active at the time of inspection. The individual treatment plan was completed on August 29, 2024 and the first update was due no later than October 29, 2024; however, the update was not completed until February 5, 2025.
Client # 2 was admitted on October 4, 2024 and was active at the time of inspection. A treatment plan update was completed on November 25, 2024 and the next update was due no later than January 25, 2025; however, the update was not completed until February 10, 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Director will be completing weekly chart checks of client paperwork to ensure that all required clinical documentation is completed in a timely manner and per policy. Clinical director will check every Friday and report out Monday prior to the clinical team meeting. The Clinical Director will outreach the assigned clinician to let them know that a treatment plan update is upcoming to be completed.
|