INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on (enter date) by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard Return Program 1&2 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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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to ensure a psychosocial evaluation was completed as a part of the facility's intake and admission procedures in three of seven client records reviewed.
The facility's policy and procedure manual stated the biopsychosocial evaluation of a client will be completed within 72 hours of admission.
Client #3 was admitted on June 24, 2025 and was active at the time of the inspection. The biopsychosocial evaluation was due to be completed no later than June 27, 2025; however, the evaluation was completed on June 30, 2025.
Client #5 was admitted on February 21, 2025 and was discharged on April 22, 2025. The biopsychosocial evaluation was due to be completed no later than February 24, 2025; however, the evaluation was completed on February 26, 2025.
Client #7 was admitted on May 23, 2025 and was discharged on June 16, 2025. The biopsychosocial evaluation was due to be completed no later than May 26, 2025; however, the evaluation was completed on May 30, 2025.
This is a repeat citation from the August 15, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will ensure that biopsychosocial evaluations are completed within 72 hours of the clients' admission, as per regulations and facility policy. Clinical Supervisor will re-educate the counselors as to the importance of adhering to the timeframe for the completion of biopsychosocial evaluations.
a). Responsible Party:
Counselors and Clinical Supervisor.
b). Completion Date: 9/30/2025
Clinical Supervisor will conduct focus audit of 5 charts per counselor, of clients admitted, ensuring that the biopsychosocial is completed as part of the intake and admission process, during a 2-month period.
a). Responsible Party:
Clinical Supervisor,
b). Completion Date: 11/30/2025
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client, per facility policy, in seven of seven client records reviewed.
The facility's policy and procedure manual stated the comprehensive (individual) treatment plan will be completed within 7 days of admission.
Client #1 was admitted on June 23, 2025 and was active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than June 30, 2025; however, the plan was completed on July 28, 2025.
Client #2 was admitted on June 23, 2025 and was active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than June 30, 2025; however, the plan was completed on July 3, 2025.
Client #3 was admitted on June 24, 2025 and was active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than July 1, 2025; however, the plan was completed on July 3, 2025.
Client #4 was admitted on April 17, 2025 and was discharged on April 30, 2025. The comprehensive treatment plan was due to be completed no later than April 24, 2025; however, the plan was completed on April 25, 2025.
Client #5 was admitted on February 21, 2025 and was discharged on April 22, 2025. The comprehensive treatment plan was due to be completed no later than February 28, 2025; however, the plan was completed on March 4, 2025.
Client #6 was admitted on May 1, 2025 and was discharged on May 9, 2025. The comprehensive treatment plan was due to be completed no later than May 7, 2025; however, the plan was completed on May 12, 2025.
Client #7 was admitted on May 23, 2025 and was discharged on June 16, 2025. The comprehensive treatment plan was due to be completed no later than May 30, 2025; however, the plan was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plans will be developed within 7 days of admission with the client as per regulations and facility policy. Clinical Supervisor will re-educate the counselors as to the importance of adhering to the timeframe .
a). Responsible Party:
Counselors and Clinical Supervisor.
b). Completion Date: 9/30/2025
Clinical Supervisor will conduct focus audit of 5 charts per counselor during a 2-month period to ensure compliance with the treatment plan regulation and policy.
a). Responsible Party:
Clinical Supervisor,
b). Completion Date: 11/30/2025
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in two of three applicable client records reviewed.
Client #2 was admitted on June 23, 2025 and was active at the time of the inspection. The comprehensive treatment plan was completed on July 3, 2025 and the first update was due to be completed no later than August 3, 2025; however, the update was not completed at the time of the inspection.
Client #3 was admitted on June 24, 2025 and was active at the time of the inspection. The comprehensive treatment plan was completed on July 3, 2025 and the first update was due to be completed no later than August 3, 2025; however, the update was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will ensure that treatment plans are reviewed and updated at least every 30 days, as per regulations and facility policy. Clinical Supervisor will re-educate the counselors as to the importance of adhering to the timeframe for the completion of treatment plans.
a). Responsible Party:
Counselors and Clinical Supervisor
b). Completion Date: 9/30/2025
Clinical Supervisor will conduct focus audit of 5 charts per counselor during a 2-month period to ensure compliance with the treatment plan updates regulation and policy.
a). Responsible Party:
Clinical Supervisor
b). Completion Date: 11/30/2025
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