INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 15-16, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Resolutions Recovery Center, 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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709.52(a)(3) LICENSURE Support service type
709.52. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed types of supportive services in the individual treatment plan in five of seven client records.
Client #1 was admitted on January 9, 2023 and was still active at the time of the inspection. No treatment plans in the record included proposed types of supportive services.
Client #2 was admitted on February 2, 2023 and was still active at the time of the inspection. No treatment plans in the record included proposed types of supportive services.
Client #3 was admitted on January 18, 2023 and was still active at the time of the inspection. No treatment plans in the record included proposed types of supportive services.
Client #4 was admitted on September 28, 2022 and was discharged on October 24, 2022. No treatment plans in the record included proposed types of supportive services.
Client #5 was admitted on September 7, 2022 and was discharged on October 25, 2022. No treatment plans in the record included proposed types of supportive services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Resolutions Recovery Center's support services were added to the template of the electronic treatment plan. All current clients received updated treatment plans. All future clients will have the support services in their treatment plans. The support services information was added to the treatment plan template within the EMR system utilized by Resolutions Recovery Center. These support services will be updated and maintained by the Facility Director and Program Director as support services change. Counselors will maintain up to date support services for the clients participating in services. These are individually bases. Support Services will be address in the AM during morning meetings to address issues or changes. This will be reported by the counselors to Program Director and Facility Director. Attendance of the morning meeting is Facility Director, Program Director, Counselors, RN's, LPN's and case manager. These steps are put in place to ensure that these deficiencies do not occur again.
Facility Director and Program Director are responsible for monitoring. Counselors will provide information if or when services need to be updated, reviewed, or changed.
Client #1 support services were added to treatment plan. Support services are individualized to client #1.
Client #2 support services were added to treatment plan. Support services are individualized to client #2.
Client #3 support services were added to treatment plan. Support services are individualized to client #3.
Client #4 discharged client. Client did participate in support services; however, it was not documented in treatment plan. As of 3/30/2023 support services will be added to all client's treatment plans. These treatment plans are individualized to each person.
Client #5 discharged client. Client did participate in support services; however, it was not documented in treatment plan. As of 3/30/2023 support services will be added to all client's treatment plans. These treatment plans are individualized to each person. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records and a discussion with staff, the facility failed to document work done by the client at the project in the treatment plan in seven of seven clients records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients have and continue to be assign chores throughout the facility. Work Therapy was added to all current client treatment plans and will be added to all future client treatment plans. Facility Director and Program Director added work therapy to the template of the treatment plan, this was updated in the EMR system. Work therapy is client focused and individualized.
This will be tracked and updated by counselors to be added in the treatment plan. This will occur in daily morning meeting. Attendance of morning meeting is Counselors, Case Manager, Program Director, Facility Director, RN, and LPN. Program Director and Facility Director completed a list of all chores offered to all clients at Resolutions Recovery Center. This list of chores was added to the treatment plan template in the EMR system. This will ensure that this deficient will not occur again. |