INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 January 13, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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, Allied Addiction Recovery, LLC 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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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
The facility failed to document case consultations as per the facility policy, which states they will be completed every 60 days along with the treatment plan updates.Client #1 was admitted on October 9, 2019 and is currently an active client. There was no evidence that case consultations occurred in client record #1.Client #3 was admitted on May 11, 2020 and discharged September 23, 2020. There was no evidence that case consultations occurred in client record #3.Client #4 was admitted on March 20, 2020 and is currently an active client. There was no evidence that case consultations occurred in client record #4.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/18/2021 Clinical Director met with Clinical staff member for training purposes. AAR clinical policy and procedure was read and reviewed. MTP and TPU with case consultations were reviewed, timelines & due dates reviewed along with content of case consults.
Ongoing weekly review will be done by Clinical Director to monitor adherence and quality of improvement to aid therapist in probationary employment documentation training. Clinical Director will schedule weekly case consultation time with therapist beginning 1/18/2021. |