INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 28, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Chartiers Community Mental Health and Retardation Center, 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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709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on applicable client records reviewed, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in six of seven client records.
Client #1 was admitted on October 2, 2023 and still active at the time of the inspection. There was no documentation of written acknowledgement from the client that they had been made aware of their rights.
Client #2 was admitted on October 10, 2023 and still active at the time of the inspection. There was no documentation of written acknowledgement from the client that they had been made aware of their rights.
Client #3 was admitted on August 2, 2023 and still active at the time of the inspection. There was no documentation of written acknowledgement from the client that they had been made aware of their rights.
Client #4 was admitted on September 26, 2023 and still active at the time of the inspection. There was no documentation of written acknowledgement from the client that they had been made aware of their rights.
Client #5 was admitted on August 15, 2023 and still active at the time of the inspection. There was no documentation of written acknowledgement from the client that they had been made aware of their rights.
Client #7 was admitted on August 14, 2023 and discharged on November 15, 2023. There was no documentation of written acknowledgement from the client that they had been made aware of their rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been retrained by the Assistant Chief Clinical Officer. As of 12/13/2023, clients are being given a Participant Handbook which documents their rights. Written documentation of notification and receipt of those rights will be captured in our electronic record.
Clinicians will be doing this process for new clients, as well any active client who does not have documented receipt of their rights. By no later than 2/1/2024, all clients will have documented receipt of their rights. This process has been implemented by the Assistant Chief Clinical Officer as of 12/20/2023.
Facility Director will monitor this process for compliance and to ensure that this deficiency does not recur. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan that included short and long-term goals for treatment in six of seven client records.
Client #1 was admitted on October 2, 2023 and still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on October 5, 2023 and did not include documentation of short and long-term goals.
Client #2 was admitted on October 10, 2023 and still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on October 10, 2023 and did not include documentation of short and long-term goals.
Client #4 was admitted on September 26, 2023 and still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on September 26, 2023 and did not include documentation of short and long-term goals.
Client #5 was admitted on August 15, 2023 and still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on August 15, 2023 and did not include documentation of short and long-term goals.
Client #6 was admitted on September 27, 2023 and still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on September 27, 2023 and did not include documentation of short and long-term goals.
Client #7 was admitted on August 14, 2023 and discharged on November 15, 2023. The comprehensive treatment and rehabilitation plan was developed on August 14, 2023 and did not include documentation of short and long-term goals.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be retrained on the necessity of having both long and short term goals. Specifically, the Goal will be a client's desired outcome 6 months to a year from initiation. The Objective will be measurable progress toward that goal, but will be a step that can be realistically achieved in the 60 days between initiation and review.
The Assistant Chief Clinical Officer will be responsible for the training and this will be accomplished by 12/31/2023. The Facility Director will be responsible for monitoring and this will begin immediately and be ongoing.
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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
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in two of five applicable records.
Client #3 was admitted on August 2, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on September 19, 2023. A treatment and rehabilitation plan update was due no later than November 19, 2023, but was not completed until November 27, 2023.
Client #7 was admitted on August 17, 2023 and was discharged on November 15, 2023. A treatment and rehabilitation plan was developed on September 14, 2023. A treatment and rehabilitation plan update was due no later than November 14, 2023, but was not completed prior to the client ' s discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 12/20/2023, staff have been re-trained on the Treatment Plan Review process by the Assistant Chief Clinical officer.
Staff will be expected to review Treatment Plans with the client before the plan expires, and if this is impossible due to scheduling or inability to contact, a Review of Treatment Progress must be completed BEFORE the Treatment Plan expires. Facility Director will review and monitor. |