This report is a result of an on-site licensure renewal inspection conducted on February 7, 2017 through February 10, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Clinical Outcomes Group Incorporated 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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Observations
Based on a review of client records, record #'s 2, 3, 6, and 7 had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.
Client #2 was admitted on 8/31/16 and was an active patient at time of inspection. A treatment plan update was completed 9/1/16 and the next update was due no later than 11/1/16; however, the update was not completed until 11/21/16.
Client #3 was admitted on 12/21/15 and was an active patient at time of inspection. A treatment plan update was completed 12/28/15 and the next update was due no later than 2/28/16. However, the update was not completed until 4/13/16. Additionally, a treatment plan update was completed 6/13/16 and the next update was due no later than 8/13/16. However, the update was not completed until 8/25/16.
Client #6 was admitted on 2/16/15 and discharged on 6/2/16. A treatment plan update was completed 1/5/16 and the next update was due no later than 3/5/16. However, the update was not completed until 3/14/16.
Client #7 was admitted on 12/4/15 and discharged on 6/1/16. A treatment plan update was completed on 2/22/16 and the next update was due no later than 4/22/16. However, there was no update completed at time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will review with all staff the treatment plan update requirements in our bi-monthly supervision by 03/08/2017. A plan will be developed in the event that counselors will be on vacation or holiday falls around the time an update is due. This will be reviewed monthly to ensure compliance. Staff will utilize task reminders in our ECR to ensure timely compliance.
The facility director will meet with the counselors of Client #2, Client #3and Client #6 to make sure appropriate addendums are completed to ensure compliance.
The facility will be in full compliance as of 03/10/2017
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