This report is a result of an on-site licensure renewal inspection conducted on March 19, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Rehab After Work, 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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Observations
Based on a review of 7 client records, 3 client records had treatment plan updates that were completed after the regulatory timeframe or missing at the time of the inspection.
Client #1 was admitted on 6/28/17 and was active at the time of inspection. A treatment plan update was completed 8/28/17 and the next update was due no later than 10/28/17. However, the update was not completed until 11/12/17. Additionally, another treatment plan update was no later than 1/12/18. However, that update was not completed until 2/6/18.
Client #2 was admitted on 8/10/17 and was active at the time of inspection. A treatment plan update was completed 8/28/17 and the next update was due no later than 10/28/17. However, the update was not completed until 11/12/17.
Client #3 was admitted on 8/29/17 and was active at the time of inspection. A treatment plan update was completed 10/31/17 and the next update was due no later than 12/31/17. However, the update was not completed until 1/9/18.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
RAW Clinical Supervisor will review the standards regarding treatment plans and treatment plan updates on at the staff meeting on 04/03/2018. RAW supervisor will review that preliminary treatment plans are due at time of level of care assessment. RAW Clinical Supervisor will review the requirement that treatment plan updates are required within 60 days of the previous plan. Master treatment plans will be due with in 4 sessions or 30days whatever the client meets first.RAW Clinical Supervisor will audit at least 10 active charts per quarter in order to assess timely completion of the treatment plan updates. Clinical Supervisor will also discuss treatment plan updates, and completing these within regulatory timeframe during each bi-weekly supervision, and weekly supervision for the next 60 days. Clinical Supervisor will review treatment plan policy regularly and provide training at New Hire Orientation. |