INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11-12, 2024, 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure that the clinical supervisor participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months of employment in that position.
Staff #2 was promoted to clinical supervisor on August 28, 2023. Clinical supervisions were reviewed for September 2023-February 2024. Monthly meetings with supervisor were not documented for September-November, 2023 and January-February, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will receive weekly supervisions for the first 60 days of employment and monthy/as needed for the next 120 days. This will be documented in a formal supervision note and saved in the training log for the employee by the Director of Clinical Services and Chief Program Officer.
Monthly supervisions resumed with Staff #2 March 2024 to present and are documented in formal supervision notes. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated every 30 days in three of six applicable records.
Client #5 was admitted to the inpatient level of care on February 16, 2024, and was still an active client at the time of inspection. An initial treatment plan was created on February 18, 2024, and the first update was due March 18, 2024. The treatment plan was not updated until March 23, 2024. The next update was due April 23, 2024, and was not completed until April 26, 2024. The next update was due May 26, 2024, and was not completed until May 27, 2024.
Client #6 was admitted to the inpatient level of care on March 19, 2024, and was still an active client at the time of inspection. An initial treatment plan was created on March 26, 2024, and the first update was due April 26, 2024. The treatment plan was not updated until April 28, 2024.
Client #7 was admitted to the inpatient level of care on March 20, 2024, and was still an active client at the time of inspection. An initial treatment plan was created on March 22, 2024, and the first update was completed April 22, 2024. The next update was due May 22, 2024, and was not completed until May 29, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The compliance component of Electronic Health Record (EHR) will be updated to show therapists and direct supervisors alerts for treatment plan updated in advance of expiration and at expiration on 07/24/2024. Assigned therapist, Clinical Supervisor, Director of Clinical Services, and Director of Operations will receive alerts prior to due date and will ensure completion to maintain compliance.
Client #5's treatment plan updates were addressed with her and signed in her chart as of 07/10/2024.
Client # 6 was discharged as of 07/10/2024 and unable to complete updates.
Client #7 was discharged as of 07/03/2024 and unable to complete updates. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of four discharged records.
The facility's policy and procedure manual states follow-up contact is to be completed for all discharges within 7 days and again within 30 days.
Client #1 was admitted to the inpatient level of care on January 16, 2024, and discharged on February 9, 2024. There were no follow-up attempts documented in client #1 ' s record.
Client #2 was admitted to the inpatient level of care on December 18, 2023, and discharged on March 1, 2024. There was no documentation of a 30 day follow-up attempt in client #2 ' s record.
Client #4 was admitted to the inpatient level of care on December 1, 2023, and discharged on March 19, 2024. There were no follow-up attempts documented in client #4 ' s record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The compliance component of Electronic Health Record (EHR) will be updated to show therapists and direct supervisors alerts for 7 and 30 day follow up, based on discharge date on 07/24/2024. Assigned therapist, Clinical supervisor, Director of Clinical Services, and Director of Operations will receive the computer alerts and ensure compliance.
Client #1, Client #2, and Client #4 have completed 7 and 30 day follow ups and have been saved to the client charts as of 07/14/2024. |