INITIAL COMMENTS
|
This report is a result of an off-site complaint investigation conducted August 16, 2022, by staff from the Bureau of Program Licensure. Based on the findings of the off-site complaint investigation, Penn Presbyterian Medical Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) 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 a review of client #1 chart documentation during a complaint investigation on August 16, 2022, the facility failed to include the frequency of treatment and rehabilitation services on the treatment plans.
Chart documentation for client #1 treatment plans included the type of services but not the frequency of services.
|
Plan of Correction
Date: 8/25/2022
Status: Completed
Responsible Party: Program Director
Director held documentation training with counseling staff on 8/24/2022 including standards of documentation for treatment plans to ensure they are listed as S.M.A.R.T goals - specific, measurable, achievable, relevant, and time-bound. All counselors signed off that they understood and would adhere to standards.
Date: 8/30/2022
Status: Ongoing until 3 months 100% compliance
Responsible Party: Lead Counselor
To ensure standards are met 20 charts will be checked/month by Lead Counselor until charts are at 100% compliance for SMART goals on treatment plans x 3 months. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client #1 chart documentation during a complaint investigation on August 16, 2022, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated every 60 days.
Chart documentation for client #1 showed that the treatment plan was dated 3/30/2022 and updated on 4/21/2022 and 4/29/2022. There were no treatment plan updates between May and August 2022.
|
Plan of Correction
Date: 8/25/2022
Status: Completed
Responsible Party: Program Director
Director held clinical documentation training with counseling staff on 8/24/2022 including timeframes in which treatment plans must be completed:
Initial: Within 7 days of Intake
Master Tx Plan: Within 30 days of Intake
Follow-up Tx Plans for ASAM 1.0: every 60 days after MTP, ASAM 2.1: every 30 days.
All counselors signed off that they understood and would adhere to standards.
Date: 8/30/2022
Status: Ongoing until 3 months 100% compliance
Responsible Party: Lead Counselor
To ensure standards are met 20 charts will be checked/month by Lead Counselor until charts are at 100% compliance for follow-up treatment plans. |
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client #1 chart documentation during a complaint investigation on August 16, 2022, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client #1 - The treatment plans dated 3/30/2022, 4/21/2022, and 4/29/2022 showed that the client was to receive individual and group sessions. The chart included progress notes for individual sessions but there was no evidence of group sessions being provided to the client during that time.
|
Plan of Correction
Date: 8/25/2022
Status: Completed
Responsible Party: Program Director
Director held documentation training with counseling staff on 8/24/2022 including standards of documentation for ongoing care and adherence to treatment.
If patient is not participating in recommended treatment at recommended levels this needs to be reviewed with patient, documented in session/chart and Tx. should be reassessed with patient to develop a plan where patient can be successful.
Date: 8/30/2022
Status: Ongoing until 3 months 100% compliance
Responsible Party: Lead Counselor
To ensure standards are met 20 charts will be checked/month by Lead Counselor ensuring gaps in treatment, "no-shows" for session and non-adherence to TX plan are addressed with patient, TX plan is adjusted appropriately and all is documented in chart. |