INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 5, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Familylinks 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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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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
Based on applicable client records reviewed, the facility failed to provide an initial comprehensive treatment and rehabilitation plan in accordance with the facility policy and procedure manual in two of six records reviewed. The project policy and procedure manual indicated an initial comprehensive treatment and rehabilitation plan be completed within fifteen days of admission into the program.Client #2 was admitted on February 13, 2024 and was still active at the time of the inspection. An initial comprehensive treatment plan was due no later than February 28, 2024, however this was not completed at the time of the inspection.Client #6 was admitted on October 18, 2023 and discharged on November 30, 2023 An initial comprehensive treatment plan was due no later than November 2, 2023, however this was not completed at the time of the inspection.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility has reviewed documentation timeline with clinical staff for initial treatment planning and treatment planning updates.
Program Manager will review charts monthly for the next six months or until consistently completed per agency policy and DDAP regulation.
Responsible Person: Program Manager
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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
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in one of three applicable records.Client #5 was admitted on August 24, 2023 and was discharged on February 2, 2024. A treatment and rehabilitation plan was developed on September 5, 2023. A treatment and rehabilitation plan update was due no later than November 5, 2023, however this was not completed prior to the client ' s discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed documentation timelines with clinical staff to ensure review occurs every sixty days.
Program Manager will review charts monthly to ensure treatment plans reviews are occurring and timely.
Person Responsible: Program Manager
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in three of three applicable records. The facility policy and procedure manual indicates a case consultation to occur every ninety days. Client #1 was admitted on September 27, 2023 and still active at the time of the inspection. A case consultation was due to occur no later than December 27, 2023, however this was not completed at the time of the inspection.Client #3 was admitted on October 24, 2023 and was still active at the time of the inspection. A case consultation was due to occur no later than January 14, 2024, however this was not completed at the time of the inspection.Client #5 was admitted on August 24, 2023 and discharged on February 2, 2024. A case consultation was due to occur no later than November 24, 2023, however this was not completed prior to discharge.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 21, 2023 annual licensing inspection.
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Plan of Correction
The facility has reviewed case consultation time frames with staff to ensure information was provided to all staff.
Program Manager will review charts monthly to ensure documentation is completed per the agency's established timeline.
Responsible Person: Program Manager
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