This report is a result of an on-site licensure renewal inspection conducted on January 11, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Treatment Trends, 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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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of six applicable records reviewed.Client #1 was admitted on August 15, 2023 and was still active at the time of the inspection. A treatment plan was completed on August 30, 2023 and the next update was due no later than October 30, 2023; however, the next update was not completed until November 22, 2023. Client #2 was admitted on October 9, 2023 and was still active at the time of the inspection. A treatment plan was completed on October 16, 2023 and the next update was due no later than December 16, 2023; however, it was not completed until December 28, 2023.Client #8 was admitted on April 26, 2023 and discharged on September 11, 2023. A treatment plan was completed on May 10, 2023 and the next update was due no later than July 10, 2023; however, it was not completed until July 26, 2023. The next update was due no later than September 26, 2023; however, it was not completed until October 5, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will review with their supervisors in supervision Treatment Plan Update expectations by January 31, 2024. If the client misses their scheduled session when the Treatment Plan Update is due, the assigned individual counselor will document in a DAP note the missed session and Treatment Plan will be updated and signed by individual counselor and supervisor without the client present. A printed copy will be present for the client at next session for them to sign and then will be uploaded into the client's EMR record after client's signature. This information was communicated to clinical staff on 01/16/2024 during in person staff meeting and via email for those who weren't present.
Effective 01/31/24, clinical staff will complete and review case load lists for biweekly/weekly supervision, which will indicate the date of Master Treatment plan and when updated treatment plans are due. Clinical staff in supervisorial roles will meet weekly with Program Director for supervision, which will include addressing concerns with treatment plan compliance.
All new clinical staff hired after implementation date will be trained on Treatment Plan Updates by their Supervisor within their first two weeks of hire.
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