INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on February 26, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the complaint investigation, 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
During the complaint investigation conducted on February 26, 2024, the facility failed to ensure that heaters are permanently mounted or installed.
One heater was observed at the front reception desk and the other heater was observed in the Facility Director's office.
This was discussed with facility staff during the complaint investigation
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Plan of Correction
The heaters were removed from the building by 3/1/24 and thermometers were placed in a number of locations/offices where the heat was in question. Maintenance will review temperature averages to determine if heaters will need to be installed or if current heating sources in those locations have to be adjusted to accommodate a suitable temperature. By 3/31/24 Maintenance will report to the Executive Director, their findings, and plan for heating those areas. |
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.
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Observations
Based on a review of five client records during the complaint investigation conducted on February 26, 2024, the facility failed to include on the consent to release forms that the client can revoke verbally and or in writing. The consent to release forms only allowed the client to revoke in writing to the facility.
This was addressed with facility staff during the complaint investigation.
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Plan of Correction
The consent to release form was revised and submitted to our electronic health record platform for adjustment on 3/5/24. Internal paper documents were altered to include the statement of revocation in writing or verbally, and were distributed to all programs leaders on 3/5/24. By 3/31/24, the Clinical Supervisor will inform all clients that they can revoke consents verbally and/0r writing during a morning meeting. New admits will be informed during their intake by the Intake Coordinator, until the platform has altered the electronic consent. |
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.
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Observations
Based on the interview with the executive director, review of the client handbook and review of client records during the complaint investigation conducted on February 26, 2024, the facility failed to include work therapy on the client's treatment plans. Five client records were reviewed, and clients were doing work that was not included on the client's treatment plans.
Client #1 - Admit date 1/30/2024
Pretreatment plan 1/31/24
Master Treatment plan 2/1/24
Client #2 - Admit date 1/22/24
Pretreatment Plan 1/22/24
Master Treatment plan 2/24/24
Client #3 - Admit date 1/9/24
Pretreatment plan 1/10/24 & 1/12/24
Master Treatment plan 2/15/24
Client #4 - Admit date 1/23/24
Pretreatment plan 1/23/24
Master treatment plan 1/30/24
Client #5 -Admit date 2/5/24
Pretreatment plan 2/5/24
Master treatment plan 2/6/24
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Plan of Correction
In staff meeting on 2/28/24 & 3/6/24, the topic of work therapy on treatment plans was reviewed by QA with the Clinical Team. By 3/31/24, the Counselors are to add an addendum to all treatment plans indicating that work therapy is assigned to the client. By 3/31/24, the Clinical Supervisor is to have audited all treatment plans for compliance. All new admits are to have work therapy indicated on their master treatment plan, by their counselor. Any treatment plan not in compliance will be sent back to the counselor, by the Clinical Supervisor, for resubmission. |