INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 22, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Three Rivers Youth 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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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to document that the treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of six records. Client # 3 was missing an update due to be completed by August 17, 2020. Client # 4 was missing an update due to be completed by March 2, 2020.Client # 5 was missing an update due to be completed by March 5, 2020.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility/Director will review with staff during supervision the importance of treatment plan updates and completion every 60 days
The Treatment staff will complete treatment plan updates every 60 days with clients as scheduled. If clients are not present for the treatment plan update, the staff will complete every 60 days and make adjustment as client becomes available.
The Director/Facility will review and monitor client records on a monthly basis to ensure accuracy and compliance with treatment plan updates every 60 days. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in three of seven records. Client # 4 was to receive weekly group and weekly individual counseling session according to the treatment plan dated January 2, 2020. The client received one group session in February and zero group sessions in March 2020. Client received one individual session in January and February 2020, and zero individual sessions in March 2020. Client was discharged on March 19, 2020. Client # 5 was to receive weekly group counseling session according to the treatment plan dated March 5, 2020. There were no group sessions documented from March 5, 2020 to the client's discharge on May 23, 2020.Client # 6 was to receive weekly group and bi-weekly individual counseling session according to the treatment plan dated August 20, 2019. Client received one group in September and November 2019. Client received zero groups in December 2019. Client received one individual in September and October 2019. Client was discharged on December 13, 2019. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility/Director will review and provide a refresher to staff on treatment planning and coinciding counseling services during weekly supervision and monthly team meetings.
The Treatment Staff will provide individual and group counseling sessions to clients according to their treatment plans and document otherwise.
The Facility/ Director will monitor treatment plans and record of services more closely to ensure appropriate service delivery and documentation on a monthly basis. |
709.93(a)(7) LICENSURE Client records
709.93. 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) Client-related correspondence.
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Observations
The facility failed to include client-related correspondence in the client's record in four of eight records. Client records # 1, 2, 4 and 6 contained releases for the clients' probation officer. There was no correspondence to or from the probation officer in the record. The project/facility director confirmed that weekly reports were emailed to the client's probation officer in all four records. The correspondence was not documented in the records. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project/Facility Director will work closely with staff to ensure correspondences to and from probation officers are documented in client records.
The Treatment Staff will continue to provide weekly updates to Probation Officers based on areas of consent. In addition, the staff will put all correspondences in the client file as applicable.
The Project/Facility Director will review and inspect client records on a monthly basis to ensure proper documentation is available. |
709.93(a)(11) LICENSURE Client records
709.93. 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
The facility failed to document follow-up information in one of three client records. Per facility policy, follow up is to be completed within six months. Client # 7 was discharged on February 22, 2020. Follow up was to be completed by August 22, 2020. There was no documentation that follow-up had been completed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project/Facility Director will meet with staff to review procedures on follow-up services during weekly supervision and monthly team meeting.
The Treatment Staff will ensure that follow-up services to clients are completed with six months and documented accordingly.
The Project/Facility Director will review client records more closely to ensure follow-ups are completed within a timely manner. |