INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ellen O ' Brien Addiction Center 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(a)(3) 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:
(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 four of seven client records.
Client #2 was admitted on February 15, 2023 and discharged on July 19, 2023. No treatment plans in the record included proposed types of supportive services.
Client #3 was admitted on March 29, 2023 and discharged on June 8, 2023. No treatment plans in the record included proposed types of supportive services.
Client #4 was admitted on May 3, 2023 and discharged on July 11, 2023. No treatment plans in the record included proposed types of supportive services.
Client #5 was admitted on March 2, 2023 and still active at the time of the inspection. 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
Clinical Director and Outpatient Supervisor will host a treatment plan training on 9/15/23 to review treatment plan requirements with staff. The treatment plans will then be monitored for compliance by clinical lead and outpatient supervisor following the training. |
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
Based on applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in two of three client records. The policy and procedure manual indicates follow-up contact must be within seven days of discharge.
Client #3 was admitted on March 29, 2023 and discharged on June 8, 2023. Follow-up contact was due to be completed no later than June 15, 2023 however, this was not completed at the time of the inspection.
Client #4 was admitted on May 3, 2023 and was discharged on July 11, 2023. Follow-up contact was due to be completed no later than July 18, 2023 however, this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director and Outpatient Supervisor will host a treatment plan training on 9/15/23 to review follow-up requirements and documentation with staff. The treatment plans will then be monitored for compliance by clinical lead and outpatient supervisor following the training. |