INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8-9, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Abstinent Living at the Turning Point at Washington Women with Children Program 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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709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document familiarization of the fee schedule to the clients during intake procedures in six of six applicable records.
There was no documentation of client familiarization of the fee schedule in the record for clients #1, 2, 4, 5, 6, and 7.
Client #1 was admitted on August 18, 2023, and discharged on January 30, 2024.
Client #2 was admitted on June 30, 2023, and discharged on December 11, 2023.
Client #4 was admitted on January 12, 2024, and was still an active client at the time of inspection.
Client #5 was admitted on January 18, 2024, and was still an active client at the time of inspection.
Client #6 was admitted on March 20, 2024, and and was still an active client at the time of inspection.
Client #7 was admitted on April 4, 2024, and was still an active client at the time of inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
We acknowledge that the fee schedule was not documented in all charts. Upon notification of this requirement, we immediately created a form indicating our fee schedule for signature by all clients upon admission to the program. The Admissions Director and Project Director will ensure this is done for all admissions into the program, and will ensure all current and future clients are compliant. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan in accordance with their policy in three of six applicable records.
Facility policy states that initial treatment plans are to be completed within two weeks of admission.
Client #1 was admitted on August 8, 2023, and discharged on January 30, 2024. The initial treatment plan was due by September 1, 2023. The treatment plan for client #1 was not completed until September 12, 2023.
Client #2 was admitted on June 30, 2023, and discharged on December 11, 2023. The initial treatment plan was due by July 14, 2023. The treatment plan for client #2 was not completed until July 19, 2023.
Client #4 was admitted on January 12, 2024, and was still an active client at the time of inspection. The initial treatment plan was due by January 26, 2024. The treatment plan for client #3 was not completed until January 31, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
We acknowledge that 3 clients had the initial treatment plan completed within 30 days, and not within 2 weeks, as indicated in our policy. After discussion with the Project Director and Clinical Director, it was determined that because the therapists develop a preliminary treatment plan within the first 24 hours, we would change our policy for the initial treatment plan to be completed within the first 30 days. The policy was updated immediately. The Project Director reviewed the new policy with all therapists during the bi-weekly clinical meeting. The Admissions Director and/or Project Director will review charts weekly and ensure all initial treatment plans are documented properly. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 the clients received counseling services according to their individual treatment plan in four of six applicable records.
Client #1 was admitted on August 18, 2023, and discharged on January 30, 2024. The initial treatment plan and all updates indicated that the client was to have one individual therapy session per week. There was no documented individual session or noted cancelation for weeks of August 27-September 2, 2023, September 17-23, 2023, October 22-28, 2023, and December 24-30, 2023.
Client #2 was admitted on June 30, 2023, and discharged on December 11, 2023. The initial treatment plan and all updates indicated that the client was to have one individual therapy session per week. There was no documented individual session or noted cancelation for weeks of July 9-15, 2023, July 16-22, 2023, August 20-26, 2023, August 27-September 2, 2023, October 15-21, 2023, November 5-11, 2023, and December 3-9, 2023.
Client #3 was admitted on February 27, 2023, and discharged on September 14, 2023. The initial treatment plan and all updates indicated that the client was to have one individual therapy session per week. There was no documented individual session or noted cancelation for weeks of April 9-15, 2023, April 16-22, 2023, May 21-27, 2023, July 16-22, 2023, and August 20-26, 2023.
Client #4 was admitted on January 12, 2024, and was still an active client at the time of inspection. The initial treatment plan and all updates indicated that the client was to have one individual therapy session per week. There was no documented individual session or noted cancelation for weeks of January 14-20, 2024, and January 28-February 3, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
We acknowledge that 3 clients did not have documented individual sessions every week. This program is dedicated to ensuring that all clients receive an individual session every week. Our Project Director reviewed this requirement again with all therapists during the bi-weekly clinical meeting. All therapists were instructed to document all individual therapy sessions, to include any cancellations. The Admissions Director and/or Project Director will review charts weekly and ensure all sessions are documented properly. |