INITIAL COMMENTS
|
This report is a result of an on-site provisional license follow-up inspection conducted on November 2, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MCP/Caring Together 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
|
711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for developing and documenting an individual's comprehensive treatment and rehabilitation plan was submitted and approved by the Department for the April 8, 2021 and April 20, 2022 annual licensing inspections. Developing and documenting an individual's comprehensive treatment and rehabilitation plan was again found to be a deficiency in the November 2, 2022, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director will present a training that highlights the importance of timely treatment plans.
The new EMR is being developed to include alerts for the timeliness of treatment plans. To ensure that ALL treatment plans are timely, the Program Director will develop a spreadsheet for all clients, including new admissions that note the due dates. Program Director will send out alerts informing team of upcoming due dates. This will be done until the EMR is able to send alerts |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of client records, the facility failed to develop and document the individual's comprehensive treatment and rehabilitation plan with the client in one of two applicable client records reviewed.
Client #2 was admitted on May 31, 2022 and was active at the time of inspection. There was no documentation of a comprehensive treatment plan in the record at the time of the inspection.
This is a repeat citation from the April 8, 2021, and April 20, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director will retrain staff on the timeliness of Comprehensive Treatment Plans.
The EMR being developed will send alerts that there is a need to develop a Comprehensive Treatment Plan.
As we await the development of the EMR, Program Director, will review all new charts to ensure that the Comprehensive Treatment Plan is completed 2 weeks prior to the due date. This information will be listed on a Spreadsheet that will include all clients. |
711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in the client's comprehensive treatment plan in one of one applicable client record reviewed.
Client #1 was admitted on August 29, 2022 and was active at time of inspection. The comprehensive treatment plan was completed on September 19, 2022; however, the plan did not include the type and frequency of treatment and rehabilitation services to be provided to the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director will retrain staff on the completion of treatment plans.
The new EMR that is still in the developmental phase will include the need to document the type and frequency of services.
Until the EMR is developed to incorporate the type and frequency of services, the Program Director will monitor the treatment plans to ensure that there is documentation of these services. Treatment Plans that do not include this information, will be returned to staff for correction. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
|
Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client on release of information forms in one of seven client records reviewed.
Client #1 was admitted on August 29, 2022 and was active at the time of inspection. A release of information form to a urinalysis laboratory was signed and dated by the client on August 29, 2022; however, there was no documentation that a copy of the form was offered to the client.
This is a repeat citation from the April 20, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All staff will be retrained regarding the completion of Release of Information Forms.
Program Director will continue to monitor the completion of forms to ensure that there is indication that clients are offered a copy.
After the training, the Program Director will review the Release of Information Forms within 72 hours of completion. Forms not correct, will be immediately addressed with staff and client will be offered a copy of the form.
|