INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Resources for Human Development 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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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the client's individual and rehabilitation plan in three of five applicable client records reviewed.
Client #2 was admitted on December 21, 2022 and was active at the time of inspection. The treatment and rehabilitation plan, completed on January 20, 2023, did not include the type of treatment and rehabilitation services to be provided.
Client #3 was admitted on March 29, 2023 and was active at the time of inspection. The treatment and rehabilitation plan, completed on April 14, 2023, did not include the type of treatment and rehabilitation services to be provided.
Client #4 was admitted on March 30, 2023 and was active at the time of inspection. The treatment and rehabilitation plan, completed on April 27, 2023, did not include the type of treatment and rehabilitation services to be provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client charts identified as deficient have had type of treatment and rehabilitation services added to their treatment plans.
Clinical staff have been re-trained on the completion of treatment plans, and all future treatment plans will include documentation of both the type and frequency of treatment and rehabilitation services.
Adherence will be monitored at least monthly by Clinical Manager or Program Director as part of the internal chart review process. |
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
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in three of four applicable client records reviewed.
Client #1 was admitted on November 16, 2022 and was active at the time of inspection. A treatment plan update was completed on February 15, 2023, and the next update was due no later than April 15, 2023; however, the update was not completed at the time of inspection.
Client #2 was admitted on December 21, 2022 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on January 20, 2023, and the first update was due no later than March 20, 2023; however, the update was not completed at the time of inspection.
Client #4 was admitted on March 30, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on April 27, 2023, the first update was due no later than June 27, 2023; however, the update was not completed at the time of inspection.
This is a repeat citation from the July 6, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan updates have been completed for both clients and staff will continue to complete treatment plan updates at least every sixty days.
Clinical staff will be re-trained on regulations related to clinical documentation and, moving forward, RHD staff will complete all treatment plan updates within the required timeframe.
This will be monitored through ongoing clinical and administrative supervision and monthly chart audits.
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709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include case consultation notes in two of two applicable client records reviewed.
Client #1 was admitted on November 16, 2022 and was active at the time of inspection. There was no documentation of case consultation notes, in the record, at the time of inspection.
Client #2 was admitted on December 21, 2022 and was active at the time of inspection. There was no documentation of case consultation notes, in the record, at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Case Consultation Notes have been completed for both clients, and staff will continue to complete Case Consultation notes at least every ninety days.
Clinical staff will be re-trained on regulations related to clinical documentation and, moving forward, RHD staff will complete all treatment plan updates within the required timeframe.
This will be monitored through ongoing clinical and administrative supervision and monthly chart audits. |