INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 7, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, SpiritLife, 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
|
Plan of Correction
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on a review of personnel records, the facility failed to provide documentation of at least one year of experience with a bachelor's degree for employee # 7.Employee # 7 was hired as a counselor on August 8, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 7's personal record and resume, there was no documentation of at least one year of clinical experience with a bachelor's degree. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 2, 2022 annual licensing inspection.
|
Plan of Correction
Clinical Director and HR supervisor reviewed regulatory expectations and updated hiring policy that dictates qualifying experience to be at least one year in the Human Service field providing clinical services (i.e. running groups, treatment planning, etc.) as qualifying experience in conjunction with a qualifying degree to be hired as a full counselor. Employee #7 was moved to Counselor Assistant until she reaches one full year of experience in August of 2023. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on two applicable employee personnel records reviewed, the facility failed to provide documentation of supervision to include one hour of direct observation for a counselor assistant in employee record # 9. Employee # 9 was hired as a counselor assistant on March 28, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 9's personal record there was no documentation of supervision that included one hour of direct observation with a bachelor's degree. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Director reviewed regulatory standards of documenting supervision and requirement of direct supervision of at least one hour for a bachelor's degree. Clinical Supervisor will submit supervision notes to Clinical Director weekly for review of documented supervision and compliance of regulatory standards. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on employee personnel records reviewed, the facility failed to provide documentation of at least 12 clock hours of annual training required for a project director for the training year January-December 2022 in employee record # 1.Employee # 1 was hired as the project director on January 1, 2015 and was still in this position at the time of the inspection. After a review of employee # 1's personnel record, there were only 7 training hours documented.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A training plan was completed for project director outlining 12 clock hours of training for training year 2023. HR Manager will conduct a quarterly evaluation of training plans to ensure staff are working towards their annual requirements including project director. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
|
Observations
Based on a physical plant inspection, a bathroom located in room 308 had an exhaust fan that was inoperable.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 2, 2022 annual licensing inspection.
|
Plan of Correction
House Stewards will walk physical plant every Wednesday to test all showers and exhaust (vent) fans and document accordingly on inspection sheet. Once the inspection is completed, documentation will be given to Maintenace supervisor along with any necessary work orders to address concerns. Maintenance supervisor will spot check rooms twice monthly to ensure accuracy of checks and documentation. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
|
Observations
Based on a physical plant inspection, the facility failed to keep cooking and eating utensils in a clean and enclosed area. Silverware was being stored in bins that were not covered and were on trays in the kitchen area. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Director of Food Services addressed on keeping silverware in covered containers at all times. Several silverware containers with lids have been purchased and will be utilized moving forward. Director of food services will conduct weekly walkthroughs of kitchen to ensure kitchen staff are in compliance with regulatory standards. |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
|
Observations
Based on a physical plant inspection, the facility failed to store all food items off the floor. Food items were stored on the floor in the walk-in freezer.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 2, 2022 annual licensing inspection.
|
Plan of Correction
Kitchen staff were educated on regulatory standards of food storage. Director of food services will be responsible for weekly review of kitchen area and food storage to ensure all food is stored properly on shelving in the cooler and food storage area. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on the review of the facility's fire drill log for the months of January 2022 through December 2022, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There were no overnight fire drills conducted January 2022 through December 2022.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Maintenance Supervisor was addressed on proper documentation of Fire Drills as AM times were marked as PM. Maintenace Supervisor will meet with Clinical Director on a bi-monthly basis to review and schedule Fire Drills. Maintenance Supervisor will also be required to review drills with Director monthly to ensure drills are done to regulatory standards. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
|
Observations
Based on a review of the facility fire drill log for the months of January 2022 through December 2022, the facility failed to provide documentation of a fire drill being conducted on different days of the week, at different times of the day and night and on different staffing shifts. Six fire drills were conducted at 11:30 am.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Director reviewed fire drill regulations with Maintenace supervisor. Maintenance Supervisor will rotate morning, afternoon, evenings and overnight drills and ensure drills are being completed on multiple different days of the week to remain in compliance with fire drill regulations. Clinical Supervisor will review fire drills monthly to ensure compliance with regulatory standards. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on review of the facility policy and procedure manual, the facility failed to provide documentation of the project director preparing, annually updating, and signing a written manual delineating project policies and procedures. The policy and procedure manual was not annually updated by signature for the year 2021 or 2022.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director reviewed project policies and procedure manual and signed that the manual was reviewed on 3/27/23. HR Manager and Clinical Director will be responsible for ensuring the annual review and updates, including signing off on the manual on an annual basis. |
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.
|
Observations
Based on three of three applicable client records reviewed, the facility failed to provide documentation of the emergency contact being notified for a client leaving against medical advice in accordance with the facility policy and procedure manual in client records # 5, 6, and 11.Client # 5 was admitted on November 25, 2022 and discharged November 30, 2022. There was no documentation of an emergency contact being notified of the client leaving against medical advice.Client # 6 was admitted on July 10, 2022 and discharged July 15, 2022. There was no documentation of an emergency contact being notified of the client leaving against medical advice.Client # 11 was admitted on May 18, 2022 and discharged May 26, 2022. There was no documentation of an emergency contact being notified of the client leaving against medical advice.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Nursing Supervisor reviewed proper documentation of emergency contacts being notified. Nursing staff will utilize nursing discharge summary form to document who was contacted and at what number prior to client leaving the facility. Nursing Supervisor will monitor discharge forms weekly for compliance. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
|
Observations
Based on one of twelve client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client record # 9. Client # 9 was admitted on January 13, 2023 and was still active at the time of the inspection. A review of client records and discussion with facility administration indicated funding was being provided however, there was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 2, 2022 annual licensing inspection.
|
Plan of Correction
Clinical Director reviewed audit findings with nursing supervisor. Nursing supervisor issued a re-train on confidentiality and the releases for funding sources. Nursing Supervisor will be responsible for weekly audits of client charts to ensure releases for funding sources are present in the charts. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on four of twelve client records reviewed, the facility failed to document written acknowledgement by clients they have been notified of their rights to include the project cannot discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. Client # 5 was admitted on November 25, 2022 and discharged November 30, 2022. Color and sex were missing from the client's acknowledgement of their rights. Client # 6 was admitted on July 10, 2022 and discharged July 15, 2022. Color and sex were missing from the client's acknowledgement of their rights. Client # 11 was admitted on May 25, 2022 and was discharged May 26, 2022. Color and sex were missing from the client's acknowledgement of their rights. Client # 12 was admitted on July 8, 2022 and discharged August 10, 2022. Color and sex were missing from the client's acknowledgement of their rights. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the March 2, 2022 annual licensing inspection.
|
Plan of Correction
Clinical Director removed all previous copies of the client handbook to ensure the most recent copy states "SpiritLife does not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion." Update was disseminated to all departments and Clinical Director will do quarterly chart reviews to ensure the most recent documentation is being utilized. |
709.63(a)(7) LICENSURE Discharge summary
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:
(7) Discharge summary.
|
Observations
Based on two of three applicable detoxification client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a discharge summary be completed within seven days of discharge.Client # 4 was admitted on February 21, 2023 and discharged on March 2, 2023. There was no discharge summary documented in the client record.Client # 6 was admitted on July 10, 2022 and discharged on July 15, 2022. There was no discharge summary documented in the client record.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Director met with Withdrawal Management Supervisor and Admissions Director to review discharge summary expectations policy. Staff was provided overview of appropriate documentation and required completion. Withdrawal Management supervisor will review charts weekly to ensure completion of discharge summaries. |
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.
|
Observations
Based on one of one applicable detoxification client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate follow-up information be completed within seven days of discharge.Client # 5 was admitted on November 25, 2022 and discharged on November 30, 2022. There was no follow-up information documented in the client record.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Director met with Withdrawal Management staff to review 7 day follow up call policy and expectations. Withdrawal Management supervisor will complete weekly reviews of charts to ensure 7 day follow up calls are completed and filed in the charts. |
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:
|
Observations
Based on four of five applicable residential client records reviewed, the facility failed to provide treatment and rehabilitation plans within two days of admission in accordance to the facility policy and procedure manual in client records # 7, 8, 9, and 12.Client # 7 was admitted on February 23, 2023 and was still active at the time of the inspection. The comprehensive rehabilitation and treatment plan was due no later than February 25, 2023; however, a comprehensive rehabilitation and treatment plan did not occur.Client # 8 was admitted on February 22, 2023 and was still active at the time of the inspection. The comprehensive rehabilitation and treatment plan was due no later than February 24, 2022; however, a comprehensive rehabilitation and treatment plan did not occur until March 2, 2023.Client # 9 was admitted on January 13, 2023 and was still active at the time of the inspection. The comprehensive rehabilitation and treatment plan was due no later than January 15, 2022; however, a comprehensive rehabilitation and treatment plan did not occur until January 23, 2023.Client # 12 was admitted on July 8, 2022 and was still active at the time of the inspection. The comprehensive rehabilitation and treatment plan was due no later than July 10, 2023; however, a comprehensive rehabilitation and treatment plan did not occur.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Director updated policy on comprehensive treatment plans to reflect completion within 72 hours of admission to accommodate weekends. The Clinical Supervisor will review new policy regarding treatment planning with each clinical staff by 3/30/23. The Clinical Supervisor will document that policy was reviewed by counselor and staff. Clinical Supervisor will conduct audits of counselor's charts weekly to identify compliance with policies and procedures. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on one of three applicable residential client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services. Client # 8 was admitted on February 22, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on March 2, 2023 however, there was no documentation frequency of services for individual sessions.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Supervisor met with clinicians to review treatment planning expectations including frequency of services and documenting accurately to reflect the hours of services provided and having appropriate notes to support the frequency of services provided. Clinical supervisor will review treatment plans weekly to ensure frequency is documented and supported. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on two of three applicable residential client records reviewed, the facility failed to provide documentation that counseling services are being provided according to the individual treatment and rehabilitation plan in client records # 9 and 10. Client # 9 was admitted on January 23, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on January 23, 2023 indicating 15 groups a week and 1 individual a week. A review of progress notes and record of service indicates an individual session occurred on January 30, 2023. The next individual session was due February 6, 2023 but did not occur until February 13, 2023. The last documented individual session occurred on February 22, 2023. Client # 10 was admitted on February 16, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on February 17, 2023 indicating Individual and small groups daily. A review of progress notes and record of service from February 16 through March 6, 2023 indicates only four individual sessions.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 2, 2022 annual licensing inspection.
|
Plan of Correction
Clinical Director and Clinical Supervisor met with clinical team on 3/28/23 to review treatment planning expectations and how to properly document frequency and amount of services provided on a weekly basis to reflect accurate number of services provided. Clinical Supervisor will monitor treatment plans weekly to ensure compliance. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
|
Observations
Based on six residential client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation to occur within 7 days of admission and then every ninety days.Client # 7 was admitted on February 23, 2023 and was still active at the time of the inspection. A case consultation was due to occur no later than March 2, 2023. There was no case consultation documented in the client record.Client # 8 was admitted on February 22, 2023 and was still active at the time of the inspection. A case consultation was due to occur no later than March 1, 2023. There was no case consultation documented in the client record.Client # 9 was admitted on January 13, 2023 and was still active at the time of the inspection. A case consultation was due to occur no later than January 20, 2023. There was no case consultation documented in the client record.Client # 10 was admitted on February 16, 2023 and was still active at the time of the inspection. A case consultation was due to occur no later than February 23, 2023. There was no case consultation documented in the client record.Client # 11 was admitted on May 18, 2022 and was discharged May 26, 2022. A case consultation was due to occur no later than May 25, 2022. There was no case consultation documented in the client record.Client # 12 was admitted on July 8, 2022 and was discharged August 10, 2022. A case consultation was due to occur no later than July 15, 2022. There was no case consultation documented in the client record.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will review policy regarding case consultations (case consultations will occur within 7 days of admission, and then every ninety days) with each clinical staff by 3/30/23. The Clinical Supervisor will document that policy was reviewed by counselor and staff. Clinical Supervisor will conduct audits of counselor's charts weekly to identify compliance with policies and procedures. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
|
Observations
Based on one out of two applicable residential client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a discharge summary be completed within 7 days of discharge.Client # 12 was admitted on July 8, 2022 and discharged on August 10, 2022. There was no discharge summary documented in the client record.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Withdrawal Management staff were trained on completing discharge summaries within 24 hours of discharge of client that includes information on their treatment stay and continuing care plan. Withdrawal Management supervisor will complete weekly chart reviews to ensure discharge summaries are completed and filed within a timely manner. |
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.
|
Observations
Based on two of two applicable residential client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate follow-up information be completed within 7 days of discharge.Client # 11 was admitted on May 18, 2022 and discharged on May 26, 2022. There was no follow-up information documented in the client record.Client # 12 was admitted on July 8, 2022 and discharged on August 10, 2022. There was no follow-up information documented in the client record.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Withdrawal management staff were re-educated on policy of 7 day follow up calls and content. Withdrawal management staff will complete the 7 day follow up calls and scan document into chart. Withdrawal Management supervisor will do weekly chart checks to ensure 7 day follow up calls are being completed. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
|
Observations
Based on three of three applicable residential client records reviewed, the facility failed to provide a complete client record to include verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan.Client # 8 was admitted on February 22, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan developed with the client on March 2, 2023 did not include verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan.Client # 9 was admitted on January 13, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan developed with the client on January 23, 2023 did not include verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan.Client # 10 was admitted on February 16, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan developed with the client on February 17, 2023 did not include verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Counselors will be trained on writing treatment plans on 4/13/23 including assessing appropriateness of work done as an integral part of the individual's treatment plan. Treatment plans will incorporate an objective to address chores being completed during their treatment stay if deemed appropriate to the client.
Clinical Supervisor will conduct weekly treatment plan reviews to ensure compliance. |