INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, WPIC Center for Psychiatric and Chemical Dependency Services 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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711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) 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 applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in four of seven records.
Client #1 was admitted on December 18, 2024 and was discharged on July 9, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on January 23, 2025, however, there was no documentation of type and frequency of services.
Client #3 was admitted on November 13, 2024 and was discharged on May 27, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on November 20, 2024, however, there was no documentation of type and frequency of services.
Client #4 was admitted on February 18, 2025 and was discharged on June 2, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on February 21, 2025, however, there was no documentation of type and frequency of services.
Client #7 was admitted on November 5, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on December 27, 2024, however, there was no documentation of type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director and supervisor will educate all clinical staff on the findings from DDAP licensure at next staff meeting on 8/19/2025 and collect a signature page of staff's attendance. If a staff member is not in attendance, then supervisor will review the citations with the staff during supervision and have staff sign off on the education.
Program director and supervisor will educate all clinical staff at the next staff meeting on 8/19/25 on the use of a "smart phrase" to ensure that both type and frequency are included in the comprehensive treatment plan.
During monthly chart audits, starting Sept 1, 2025, supervisor will ensure that both "type and frequency" are included in the comprehensive treatment plan. If one or both are not present, supervisor will document outreach to clinician to update. Once updated, Supervisor will ensure accuracy of documentation.
It should be noted that all clients in this audit are discharged; therefore, no further updates are needed. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in three of seven applicable records.
Client #1 was admitted on December 18, 2024 and was discharged on July 9, 2025. A treatment and rehabilitation plan was developed on January 23, 2025. A treatment and rehabilitation plan update was due no later than March 23, 2025, but was not completed until April 2, 2025.
Additionally, the next update was due no later than June 2, 2025; however, the update was not completed prior to discharge.
Client #3 was admitted on November 13, 2024 and was discharged on May 27, 2025. A treatment and rehabilitation plan was developed on November 20, 2024. A treatment and rehabilitation plan update was due no later than January 20, 2025 but was not completed until January 22, 2025.
Client #7 was admitted on November 5, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on December 27, 2024. A treatment and rehabilitation plan update was due no later than February 27, 2025 but was not completed until February 28, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director and supervisor will educate all clinical staff on the findings from DDAP licensure at next staff meeting on 8/19/2025 and collect a signature page of staff's attendance. If a staff member is not in attendance, then supervisor will review the citations with the staff during supervision and have staff sign off on the education.
Program director and supervisor will educate clinical staff at the next staff meeting 8/19/25, regarding the requirement to use their caseload tracker and weekly treatment plan reminders to ensure client's txp are updated every 60 days.
Effective 7/28/25, Supervisor runs a weekly treatment plan report from the electronic health record and sends out notification to clinical staff regarding which clients have an upcoming treatment plan due with the due date.
It should be noted that all clients in this audit are discharged; therefore, no further updates are needed
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711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) 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 five records.
The policy and procedure manual indicates follow-up contact must be made within seven days after discharge.
Client #1 was admitted on December 18, 2024 and was discharged on July 9, 2025. Follow-up contact was due to be completed no later than July 16, 2025, however, this was not completed at the time of the inspection.
Client #4 was admitted on February 18, 2025 and was discharged on June 2, 2025. Follow-up contact was due to be completed no later than June 9, 2025, however, this was not completed until June 25, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program director and supervisor will educate all clinical staff on the findings from DDAP licensure at next staff meeting on 8/19/2025 and collect a signature page of staff's attendance.
If a staff member is not in attendance, then supervisor will review the citations with the staff during supervision and have staff sign off on the education.
On a quarterly basis, starting 9/4/2025, supervisor will conduct chart audits on one discharge client for each clinical staff to ensure that follow up has been conducted within 7 days of discharge. If a follow up was not conducted, supervisor will educate staff on the requirement and will continue to monitor their discharge documentation
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