INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 5-6, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Ascend Clinical Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 include the type and frequency of services on an individual treatment and rehabilitation plan in one of four charts reviewed.
Client # 3 was admitted on December 21, 2023, and discharged on February 26, 2024. The treatment plan dated January 8, 2024, had no documentation of the type and frequency of services the client was to receive.
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Plan of Correction
By 04/15/2024, documented training will be provided to counseling staff regarding the need to identify the modality and frequency of treatment services in the individualized treatment plan. The Clinical Supervisor, in collaboration with the Compliance team, will conduct monthly chart reviews to ensure ongoing compliance with 709.92(a)(2). |
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
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in one of four records reviewed.
Client # 4 was admitted October 1, 2023, and discharged January 30, 2024. The individual treatment and rehabilitation plan dated November 12, 2023, called for one individual session every 2 weeks. There was no documentation of individual sessions the weeks of 12/3, 12/10, 12/17, 12/24, or 12/31/23.
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Plan of Correction
By 04/15/2024, documented training will be provided to counseling staff regarding the need to ensure treatment services are provided in accordance with the individualized treatment plan. The Clinical Supervisor, in collaboration with the Compliance team, will conduct monthly chart reviews to ensure ongoing compliance with 709.92(c). |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of the client records, the facility failed to provide treatment and rehabilitation services to a client on a regular and scheduled basis in one of four charts reviewed.
Client # 3 was admitted on December 21, 2023, and discharged on February 26, 2024. Documentation of individual sessions occurring was absent from January 8, 2024, through the date of discharge, February 26, 2024.
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Plan of Correction
By 04/15/2024, documented training will be provided to counseling staff regarding the need to ensure treatment services are provided on a regular and scheduled basis. The Clinical Supervisor, in collaboration with the Compliance team, will conduct monthly chart reviews to ensure ongoing compliance with 709.92(d). |