INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Pathway Services, LLC 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(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
The facility failed to provide treatment plan updates within the regulatory timeframe in three of seven client records reviewed.Client #1 was admitted on January 25, 2019 and was active at the time of inspection. The comprehensive treatment plan was completed on February 8, 2019 and the first update was due no later than April 8, 2018. However, the update was not completed at the time of the inspection. Client #4 was admitted on May 24, 2017 and was discharged on November 8, 2017. The comprehensive treatment plan was completed on June 14, 2017 and the first update was due no later than August 14, 2017. However, the update was not completed until October 11, 2017. Client #5 was admitted on June 28, 2018 and was discharged on January 17, 2019. The comprehensive treatment plan was completed on July 12, 2018 and the first update was due no later than September 17, 2018. However, the update was not completed until November 8, 2018. Additionally, the next update was due no later than January 8, 2019; however, the update was not completed prior to discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will correct the deficiency in the specified client charts by ensuring that all treatment plan updates are completed within a 60 day period.
The facility will ensure that the treatment plan updates will be reviewed and updated at least every 60 days for all clients. The lead counselor will be responsible for the treatment plan updates and the facility director will meet with the lead counselor to ensure continued compliance. The correction action date is April 10. 2019 the date of the facility inspection where the treatment plan update findings were reviewed and the facility was informed of the regulatory time frame. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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
The facility failed to assure that clients received the required counseling services according to the individual's comprehensive treatment plan in three of seven client records reviewed.Client #1 was admitted on January 25, 2019 and was active at the time of inspection. The comprehensive treatment plan, dated February 8, 2019, indicated the client was to receive one individual therapy session per week (four individual sessions per month). However, the chart's record of service and progress notes indicated that the client did not receive an individual session during the weeks of 02/11/19, 02/25/19, 03/04/19, and 03/11/19.Client #4 was admitted on May 24, 2017 and was discharged on November 8, 2017. The comprehensive treatment plan, dated June 14, 2017, indicated the client was to receive one individual therapy session per week (four individual sessions per month). However, the chart's record of service and progress notes indicated that the client did not receive an individual session during the weeks of 08/07/17, 09/04/17, 09/18/17, 10/02/17, 10/16/17, and 10/30/17.Client #5 was admitted on June 28, 2018 and was discharged on January 17, 2019. The comprehensive treatment plan, dated June 14, 2017, indicated the client was to receive one individual therapy session per week (four individual sessions per month). However, the chart's record of service and progress notes indicated that the client did not receive an individual session during the weeks of 10/08/18, 10/22/18, 10/29/18, 11/12/18, 11/26/18, 12/03/18, 12/17/18, 12/24/18, and 01/07/19.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will assure that all clients will receive the required counseling services according to the individual's comprehensive treatment plan. The lead counselor will be responsible to ensure that all client's record of service and progress notes will directly reflect the comprehensive treatment plan attendance agreement. In the event that a client does not meet the treatment plan attendance agreement an updated treatment plan will be completed reflecting the change in attendance. The project director will review the charts to ensure that all client's receive the required counseling services according to the individual's comprehensive treatment plan. The corrective action was implemented on April 10, 2019 after the inspection findings were reviewed during the licensing process. |
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.
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Observations
The facility failed to provide follow-up information in the client's complete record in three of five applicable client records reviewed.Client #3 was admitted on September 18, 2017 and was discharged on December 19, 2017.Client #4 was admitted on May 24, 2017 and was discharged on November 8, 2017.Client #6 was admitted on July 5, 2017 and was discharged on October 13. 2017.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all client charts will contain follow-up information within 90 days following the client's completion of treatment. The lead counselor will contact all client's who have completed treatment within 90 days and document the follow up information in the clients chart. The program director will meet with the lead counselor to ensure that all follow up information is completed within 90 days of client's completion of treatment.The corrective action was implemented on April 10, 2019 after the findings were reviewed with the faculty during the licensing process. |