INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on October 26, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wellness Recovery LLC 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 policy and procedure, the facility failed to document a complete written procedure for the management of treatment/rehabilitation services for clients.
The procedure for notifying emergency contacts of when an individual leaves treatment against medical advice to comply with Act 41 of 2021 was missing the time frame for completion.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 2021, January 2022, and April 2022 licensing inspection.
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Plan of Correction
The AMA discharge procedure has been updated to include the 1-hour time-frame requirement for notification of emergency contacts. The new procedure is now present in the Policy and Procedure manual on-site and all staff members have been educated on the time-frame requirement. The Facility Director is responsible for reviewing all AMA discharges and monitoring compliance with the AMA discharge procedure. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a follow up contact for clients discharged from detoxification in four of five client records.
The facility policy states discharged clients will be contacted within seven days and thirty days.
Client # 8 was admitted to detoxification on August 19, 2022 and was discharged on August 22, 2022. Follow up was due to be completed by August 29, 2022 and September 22, 2022, but was not documented as of the date of the inspection.
Client #9 was admitted to detoxification on September 15, 2022 and was discharged on September 17, 2022. Follow up was due to be completed by September 24, 2022 and October 17, 2022, but was not documented as of the date of the inspection.
Client #10 was admitted to detoxification on August 25, 2022 and was discharged on August 29, 2022. Follow up was due to be completed by September 5, 2022 and September 29, 2022, but was not documented as of the date of the inspection.
Client #11 was admitted to detoxification on September 2, 2022 and was discharged on September 5, 2022. Follow up was due to be completed by September 12, 2022 and October 5, 2022, but was not documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Per facility policy, 7 and 30 day post-discharge surveys must be conducted on all residential and detoxification patients following their departure from treatment. Documentation is maintained in the front office so that records are immediately available upon request. Counselors and Counselor Technicians have been trained in the surveying procedure. The Facility Director is responsible for ensuring completion and on-going compliance of the follow-up policy.
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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 client records, the facility failed to document a follow up contact for clients discharged from residential treatment in one of three client records.
The facility policy states discharged clients will be contacted within seven days and thirty days.
Client #2 was admitted to detoxification treatment on September 7, 2022, was transferred to residential treatment on September 13 and was discharged from residential treatment on September 21, 2022. Follow up was due to be completed by September 28, 2022 and October 21, 2022, but was not documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 2022 licensing inspection.
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Plan of Correction
Per facility policy, 7 and 30 day post-discharge surveys must be conducted on all residential and detoxification patients following their departure from treatment. Documentation is maintained in the front office so that records are immediately available upon request. Counselors and Counselor Technicians have been thoroughly trained in the surveying procedure. The Facility Director is responsible for ensuring completion and on-going compliance of the follow-up policy |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license 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.
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Observations
Based on a review of administrative information, the facility failed to comply with a plan of correction that was approved by the Department.
A plan of correction for a complete written procedure for the management of treatment/rehabilitation services for clients was submitted and approved by the Department for the May 6, 7, 20, 2021, January 14, 2022 and April 19-21, 2022 licensing inspections. Written procedures for the management of treatment/rehabilitation services for clients was again found to be a deficiency in the October 26, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All deficiencies have been reviewed by the CAP compliance committee, consisting of the facility owner, project, facility, medical, and nursing director. The committee will continue to meet weekly to oversee the correction and further compliance with policy updates. The Project Director is responsible for the committee activities and monitoring the compliance with all CAP submissions. The Facility Director is responsible for staff education, training, application of updated policy/procedures. Training and Development plans have been created for each staff member based upon individual and facility needs assessment. Evaluations have been completed on all staff members, identifying areas of performance that failed to meet performance standards, along with respective remediation steps. The facility is in the process of transitioning to electronic medical records that will reduce the amount of paperwork and increase documentation organization/retrieval. |