INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 2, 2019 through December 3, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Newvitae, 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
The facility failed to ensure that employee #2, a clinical supervisor hired on January 19, 2019, completed a core curriculum as the employee did not function for 2 years as a supervisor in the provision of clinical services prior to hiring.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
When DDAP posts the dates for the 2020 30 hour training, the Clinical Supervisor will sign up and complete the 30 hours. The training will be completed by 6/30/2020. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
The facility failed to ensure that the client received individual counseling, at least twice a week, in one of two applicable client records reviewed.
Client #2 was admitted to the partial hospitalization level of care on November 7, 2019 and was discharged on November 25, 2019. According to the record of service and progress notes, the client was only scheduled for and received one individual counseling session per week.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2
A re-training will take place to ensure that the counselors are aware that every client entering PHP will need to be seen 2xs weekly for individual therapy according to the regulatory standards. This training will be completed by the Clinical Supervisor and take place on 1/28/2020.
The training will take place every 6 months as a refresher; the Clinical Supervisor will review individual session notes quarterly to ensure clients are being seen two times weekly. The New Vitae Director will review with the Clinical Supervisor quarterly during supervision. |
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 provide treatment plan updates within the regulatory timeframe in two of two applicable client records reviewed.
Client #4 was admitted to the outpatient level of care on June 10, 2019 and was active at the time of inspection. The comprehensive treatment plan was completed on June 10, 2019 with an update due no later than August 10, 2019; however, the update wasn't completed until August 26, 2019.
Client #5 was admitted to the outpatient level of care on April 16, 2018 and was discharged on September 27, 2019. A treatment plan update was completed on February 4, 2019 with an update due no later than April 4, 2019; however, the update wasn't completed until May 1, 2019. Additionally, a treatment plan update was completed on June 19, 2019 with an update due no later than August 19, 2019; however, an update wasn't completed at the time of discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #4
A re-training will take place by 1/28/2020 with the DDAP clinicians to ensure that the outpatient treatment plans are completed within the 60 day time frame.
The Clinical Supervisor will provide the aforementioned training. This training will take place every 6 months as a refresher and treatment plans will be reviewed by the Clinical Supervisor quarterly. The Director of New Vitae Recovery Center will review treatment planning with the Clinical Supervisor quarterly during supervision.
Client #5
Listed above under client #4,the retraining will be completed by 1/28/2020 and will address this error with the Staff mentioned above. The Clincal Supervisor will complete the training and do so every six months. A review of all treatment plans will take place quarterly and the Director will review with results with the Clinical Supervisor
The Clinical Supervisor will educate counselors regarding ensuring that treatment plans remain active, even when a client has stopped coming to treatment, will be completed by 1/28/2020. A retraining will take place every 6 months and the Director will review results of treatment plan reviews quarterly.
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