INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 1, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Rehab Management 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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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document the preliminary treatment and rehabilitation plan in three of six applicable client records reviewed. Additionally, the facility failed to document the preliminary treatment and rehabilitation plan within the timeframe documented in the facility policy in three of six applicable client records reviewed.The facility policy and procedure manual states that the preliminary treatment and rehabilitation plan will be completed at the time the level of care assessment is completedClient #2 was admitted on August 1, 2022 and was discharged on September 22, 2022. There was no preliminary treatment and rehabilitation plan, documented in the record, as of the date of inspection.Client #6 was admitted on August 12, 2022 and was discharged on September 1, 2022. There was no preliminary treatment and rehabilitation plan, documented in the record, as of the date of inspection.Client #7 was admitted on October 7, 2022 and was discharged on October 24, 2022. There was no preliminary treatment and rehabilitation plan, documented in the record, as of the date of inspection.Client #8 was admitted on September 12, 2022 and was discharged on December 12, 2022. The level of care assessment was completed on September 13, 2022; however, the preliminary treatment plan was completed on October 5, 2022. Client #9 was admitted on August 10, 2022 and was discharged on September 7, 2022. The level of care assessment was completed August 11, 2022; however, the preliminary treatment plan was completed on August 17, 2022. Client #10 was admitted on July 22, 2022 and was discharged on September 2, 2022. The level of care assessment was completed July 22, 2022; however, the preliminary treatment plan was completed on July 25, 2022. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and executive director with the support of clinical director and quality manager will complete monthly chart audits to ensure treatment plans are being completed within policy timeframes. Re-training will occur during group supervision within 30 days, with expectation of full compliance by 5/28/23. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to complete an individual treatment and rehabilitation plan, which is to be developed with the client, in three of nine applicable client records reviewed. Client #2 was admitted on August 1, 2022 and was discharged on September 22, 2022. There was no individual treatment rehabilitation plan, in the record, as of the date of the inspection.Client #4 was admitted on August 26, 2022 and was discharged on November 7, 2022. There was no individual treatment rehabilitation plan, in the record, as of the date of inspection.Client #5 was admitted on August 9, 2022 and was discharged on September 20, 2022. There was no individual treatment rehabilitation plan, in the record, as of the date of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and executive director with the support of clinical director and quality manager will complete monthly chart audits to ensure individual master treatment plans are being completed within policy timeframes. Re-training will occur during group supervision within 30 days, with expectation of full compliance by 5/28/23. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan within the timeframe documented in the facility policy in four of six applicable client records reviewed.The facility policy and procedure manual states that the aftercare plan commences on intake/initial assessment and be reviewed at the final phase of treatment.Client #2 was admitted on August 1, 2022 and was discharged on September 22, 2022. The aftercare plan was due no later than September 22, 2022; however, the plan was completed on December 29, 2022.Client #4 was admitted on August 26, 2022 and was discharged on November 7, 2022. The aftercare plan was due no later than November 7, 2022; however, the plan was completed on December 30, 2022.Client #6 was admitted on August 12, 2022 and was discharged on September 1, 2022. The aftercare plan was due no later than September 1, 2022; however, the plan was completed on September 16, 2022.Client #7 was admitted on October 7, 2022 and was discharged on October 24, 2022. The aftercare plan was due no later than October 24, 2022; however, the plan was completed on November 15, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and executive director with the support of the clinical director and quality manager will review after care/discharge planning timeframes with staff during weekly group supervision. For new staff, the above staff identified will facilitate new hire orientation and on site training. Expectation of full compliance with new staff will occur no later than 6/28/2023. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to complete a discharge summary within the timeframe documented in the facility policy five of nine applicable client records reviewed.The facility policy and procedure manual states that the discharge summary will be completed within 7 business days of client discharge.Client #2 was admitted on August 1, 2022 and was discharged on September 22, 2022. The discharge summary was due no later than October 3, 2022; however, the summary was completed on December 29, 2022.Client #4 was admitted on August 26, 2022 and was discharged on November 7, 2022. The discharge summary was due no later than November 16, 2022; however, the summary was completed on December 30, 2022.Client #6 was admitted on August 12, 2022 and was discharged on September 1, 2022. The discharge summary was due no later than September 12, 2022; however, the summary was completed on September 16, 2022.Client #7 was admitted on October 7, 2022 and was discharged on October 24, 2022. The discharge summary was due no later than November 2, 2022; however, the summary was completed on November 15, 2022.Client #8 was admitted on September 12, 2022 and was discharged on December 12, 2022. The discharge summary was due no later than December 21, 2022; however, the summary was completed on December 29, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and executive director with the support of the clinical director and quality manager will review discharge summary timeframes with staff during weekly group supervision. Chart audits will occur monthly by above identified staff to ensure full compliance. For new staff, the above identified persons will facilitate new hire orientation and on site training. Full review of discharge summary policies will occur with all staff. Expectation of full compliance with staff will occur no later than 6/28/2023. |
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 a review of client records, the facility failed to complete follow-up information within the timeframe documented in the facility policy in five of eight applicable client records reviewed.The facility policy and procedure manual states that follow-up information will be completed and documented within 7 days of the client's discharge.Client #2 was admitted on August 1, 2022 and was discharged on September 22, 2022. Follow-up information was due no later than September 29, 2022; however, the follow-up was completed on December 29, 2022.Client #4 was admitted on August 26, 2022 and was discharged on November 7, 2022. Follow-up information was due no later than November 14, 2022; however, the follow-up was completed on December 30, 2022.Client #6 was admitted on August 12, 2022 and was discharged on September 1, 2022. Follow-up information was due no later than September 8, 2022; however, the follow-up was completed on September 14, 2022.Client #7 was admitted on October 7, 2022 and was discharged on October 24, 2022. Follow-up information was due no later than October 31, 2022; however, the follow-up was completed on November 11, 2022.Client #8 was admitted on September 12, 2022 and was discharged on December 12, 2022. Follow-up information was due no later than December 19, 2022; however, the follow-up was completed on December 29, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and executive director with the support of the clinical director and quality manager will review follow up call timeframes with staff during weekly group supervision. Chart audits will occur monthly by above identified persons to ensure full compliance. For new staff, the above identified persons will facilitate new hire orientation and on site training. Full review of follow up call policies will occur with all staff. Expectation of full compliance with staff will occur no later than 6/28/2023. |