INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24 - 25, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Renewal Treatment, 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to ensure project staff notified the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project in two of two records.
Client #4 was admitted to the outpatient level of care on May 26, 2023 and was discharged unsuccessfully on July 14, 2023. Client #4 ' s record did not contain documentation that the client was notified in writing that their treatment was involuntarily terminated.
Client #7 was admitted to the outpatient level of care on April 10, 2023 and was discharged unsuccessfully on April 18, 2023. Client #7 ' s record did not contain documentation that the client was notified in writing that their treatment was involuntarily terminated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients shall be notified in writing of a decision to involuntarily discharge them from the program. The Clinical Supervisor has provided training to the Counselor staff on this deficiency and this requirement. Each client's Counselor shall prepare a written letter explaining the reason for a client's involuntary termination from treatment that shall explain the reason for the involuntary discharge and shall contain information on how to appeal the decision. This letter shall be mailed to the client at their address of record. The Clinical Supervisor and the Counselor shall both sign the written letter. The Clinical Supervisor shall have direct oversight responsibility for this plan of correction and shall ensure compliance by closed chart review. This plan of correction is in place. |
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
Based on a review of client records, the facility failed to ensure counseling services were provided according to the individual treatment and rehabilitation plan in two of six records reviewed.
Client #2 was admitted to the outpatient level of care on May 17, 2023 and was active at the time of review. Client #2 ' s record contained a treatment and rehabilitation plan dated May 23, 2023 that indicated a frequency of service at a rate of one individual and one group session per week. Client #2 ' s record did not contain documentation the client was provided a group session for the week of June 6, 2023. Client #2 ' s record also did not contain documentation an individual session was provided during the weeks of June 12, June 19, June 26, and July 3, 2023.
Client #4 was admitted to the outpatient level of care on May 26. 2023 and was discharged July 14, 2023. Client #4 ' s record contained a treatment and rehabilitation plan dated June 8, 2023 that indicated a frequency of service at a rate of one individual and one group session per week. Client #4 ' s record did not contain documentation the client was provided a group session for the weeks of June 12 and June 19, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall provide treatment services according to the individual treatment and rehabilitation plan. The Clinical Supervisor provided training and instruction in regards to this deficiency and requirement to the Counselor staff. The Counselor staff shall document when a client fails to show for a scheduled treatment services either individual or group in each client's chart. Additionally, the Clinical Supervisor and Counselor staff shall ensure that treatment services are provided at a frequency (both individual and group services) to ensure that all client's receive services according to the individualized treatment plan. The Clinical Supervisor shall be responsible for oversight of this plan of correction and shall ensure compliance via regular chart review. This plan of correction is in place. |