INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 3, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, 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:
|
Plan of Correction
|
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of three discharged records reviewed. According to the facility ' s policy and procedures manual, the follow up is due within thirty days of discharge. Client #8 was admitted on February 24, 2024 and discharged on March 21, 2024. The follow up contact was due no later than April 20, 2024; however, it was not completed until May 30, 2024. Client #9 was admitted on April 15, 2024 and discharged on June 17, 2024. A follow up contact was due no later than July 17, 2024; however, it was not completed until August 2, 2024. Client #10 was admitted on February 12, 2024 and discharged on April 22, 2024. A follow up contact was due no later than May 22, 2024; however, there is no documentation that one was completed. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
To address this deficiency, on 12/13/2024 client #10 follow-up was completed, with the understanding that it is past due. It is the client's counselor or designee, such as lead counselor, clinical supervisor or director, responsibility to conduct a follow-up within 30 days of discharge. To prevent future out of compliance with follow-ups, any discharge client will remain on the counselor/designees case load review for biweekly supervision with their assigned Supervisor until follow-up is completed. The Clinical Supervisor, Lead Counselor or Program Director will periodically audit all discharge charts of their supervisee to ensure adherence to this requirement. Prior to this taking affect Program Director will complete an audit of recently discharged client's and present in staff meeting any 30 day follow-ups that are missing from the client's charts. This information will be presented in staff meeting, group supervision and counselors or designees next supervisions by 1/17/25.
|
709.42(b)(2) LICENSURE Preliminary Treatment Plan
709.42. Project management.
(b) The intake project or treatment service providers shall have a written procedure for the performance of the following functions:
(2) Preparation of a preliminary treatment plan utilizing appropriate available service resources and listing the services to be provided. This plan shall be developed in cooperation with and agreed to by the intake project or treatment service provider and the client. The service plan shall also include referral to services not specifically for drug and alcohol clients; for example, legal services and dental services for which the client may be eligible.
|
Observations
Based on a review of client records, the facility failed to prepare a preliminary treatment plan utilizing all appropriate available service resources and listing the services to be provided. This plan shall be developed in cooperation with and agreed to by the intake project or treatment service provider and the client. The service plan shall also include referral to services not specifically for drug and alcohol clients for example, legal services and dental services for which the client may be eligible in seven out of seven records reviewed. Client #1 was admitted on July 29, 2024 and discharged on July 29, 2024. There was no documentation that a preliminary treatment plan with the required information was completed. Client #2 was admitted on August 21, 2024 and discharged on August 21, 2024. There was no documentation that a preliminary treatment plan with the required information was completed. Client #3 was admitted on September 25, 2024 and discharged on September 25, 2024. There was no documentation that a preliminary treatment plan with the required information was completed. Client #4 was admitted on June 11, 2024 and discharged on June 11, 2024. There was no documentation that a preliminary treatment plan with the required information was completed. Client #5 was admitted on July 1, 2024 and discharged on July 1, 2024. There was no documentation that a preliminary treatment plan with the required information was completed. Client #6 was admitted on August 8, 2024 and discharged on August 8, 2024. There was no documentation that a preliminary treatment plan with the required information was completed. Client #7 was admitted on October 7, 2024 and discharged on October 7, 2024. There was no documentation that a preliminary treatment plan with the required information was completed. These finding were reviewed with facility staff during the licensing process.
|
Plan of Correction
To address this deficiency a Preliminary Treatment Plan form will be created by Quality Assurance Coordinator and Program Director and submitted to our EMR by February 17, 2025. Preliminary Treatment Plan will be added to the assessment encounter as a required form. Counselors/Assessors will be trained prior to it being uploaded to our EMR in group supervision, staff meeting and individual supervision by Program Director, Quality Assurance and Lead Counselor. Lead counselor, clinical supervisor or program director will review assessment documents to ensure the staff are utilizing the new form. Program Director will update policies and procedures to reflect this. |