INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 25, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Passages to Recovery 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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709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of eleven client records, the facility failed to ensure that all consent to releases for the criminal justice system contained a purpose of disclosure in all eleven client records reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Effective 6/14/22, the consent to release information for the criminal justice system has been updated to include a purpose of disclosure. This form is available upon request to review if need be.
The Clinical Supervisor will be completing a chart review within the first week to ensure that the proper form is being utilized. The Compliance team will also be completing regular chart reviews to ensure that proper documentation is being utilized on proper forms.
Old forms have been purged from the system.
The current deficiency was corrected as the clients who are still active were asked to sign a new release. All individuals going forward will sign the same release. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven inpatient client record, the facility failed to ensure that comprehensive treatment plans included the type and frequency of treatment and services in all seven client records reviewed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
A place for the type and frequency of treatment and services provided to the clients has been added to the comprehensive treatment plan effective 6/14/22. All new admissions will be required to utilize the new plan going forward and all staff will be required to add this to all current treatment plans effective immediately. All current residents had a treatment plan amendment completed to add this to their current plan.
The Clinical Supervisor will be conducting at a minimum, monthly reviews of files to ensure that this is noted on every treatment plan for every client within the program. Further, the Compliance department will be conducting follow up reviews to ensure the same thing. This will begin immediately. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of seven inpatient client records, the facility failed to provide a complete client record, which is to include aftercare plan in two of the three applicable client records.
Client #6 was admitted on December 20, 2021 and was discharged on May 5, 2022. There was not documentation of an aftercare plan being completed in the client record.
Client #7 was admitted on February 21, 2022 and was discharged on May 10, 2022. There was no documentation of an aftercare plan being completed in the client record.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
A section has been added to the chart review form to ensure that the Therapist is checking that an aftercare plan has been completed prior to discharge and that a copy of it is sent to the client within their client letter. The aftercare plan completion and review will be documented within an individual DAP note for each client prior to discharge. Further, the client letter will note that a copy of the aftercare plan was included with said letter.
The Clinical Supervisor will be responsible for completing monthly chart reviews at a minimum to ensure that this is being completed for all clients in a timely and appropriate manner. Further, the Compliance department will be conducting frequent and regular reviews of files as well for oversight.
The current deficiency was corrected as the clients who are still active were given a updated aftercare plan and all clients who have been discharged since the audit have this service documented. All individuals going forward will sign the same release. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to ensure that all work done by the client at the project is an integral part of his treatment and rehabilitation plan in all seven client records.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Work Therapy has been added to each treatment plan going forward to ensure that these services can be accounted for and included within their treatment.
Monthly chart reviews completed by the Clinical Supervisor will ensure that this is being noted on each and every treatment plan/treatment plan review. Further, the Compliance department will be conducting reviewed for additional oversight.
The current deficiency was corrected as the clients who are still active received an amendment to their current treatment plan to add work therapy. All individuals going forward will have this included on their treatment plan.
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