INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 25, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CARON OUTPATIENT SERVICES 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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709.92(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 a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of six applicable records reviewed.
Client #2 was admitted on March 8, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 8, 2024 and an update was due no later than May 8, 2024; however, it was not completed until May 16, 2024. Additionally, the next update was due no later than July 16, 2024; however, it was not completed until July 25, 2024.
Client #4 was admitted on March 20, 2024 and was still active at the time of the inspection. A treatment plan update was completed on June 12, 2024 and the next update was due no later than August 12, 2024; however, it was not completed until October 3, 2024.
Client #7 was admitted on June 26, 2024 and was discharged on November 12, 2024. A comprehensive plan update was completed on August 22, 2024 and an update was due no later than October 22, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will re-educate clinicians on individual and treatment rehabilitation plan requirements, specifically that the plan must be reviewed and updated at least every 60 days. This education will be provided during Clinical Supervision by 12/11/24. The Clinical Supervisor will do chart audits monthly to ensure that individual and treatment rehabilitation updates are completed in a timely manner. The Clinical Supervisor will report progress to the Quality Committee on a quarterly basis. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 60 days.
Client #1 was admitted on August 16, 2024 and was still active at the time of the inspection. No case consultations were documented.
Client #3 was admitted on January 23, 2024 and was still active at the time of the inspection. A case consultation was completed on March 19, 2024; and the next one was due by May 19, 2024; however, it was not completed until May 21, 2024.
Client #4 was admitted on March 20, 2024 and was still active at the time of the inspection. A case consultation was due no later than May 20, 2024; however, it was not completed until July 31, 2024.
Client #5 was admitted on admitted on July 22, 2024 and discharged on November 13, 2024. A case consultation was due no later than September 22, 2024; however, it was not completed until October 1, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will re-educate clinicians on case consultation notes, specifically that they must be completed every 60 days per policy. This education will be provided during Clinical Supervision by 12/11/24. The Clinical Supervisor will also remind the clinical team of upcoming due dates for case consultations at each weekly clinical team meeting. The Clinical Supervisor will do chart audits monthly to ensure that case consultations are completed in a timely manner. The Clinical Supervisor will report progress to the Quality Committee on a quarterly basis. |
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 document follow up information within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 10 days following discharge.
Client #6 was admitted on June 25, 2024 and discharged on August 20, 2024. A follow up was due no later than August 30, 2024; however, it was not completed until September 10, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will re-educate staff on follow up information documentation, including required timeframes by 12/11/24. The Quality Analyst will do quarterly chart reviews for the completion of follow up information documentation within required timeframes and will report progress to leadership. |