INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Care Center dba SPHS Care 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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709.91(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 a preliminary treatment plan in one out of one applicable client records.
Client #1 was admitted on July 18, 2022 and was still an active client at the time of inspection. A preliminary treatment plan was not documented for client #1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will facilitate weekly group staffing/supervision on 2/28/23 and will include a review of the SPHS internal policy and DDAP Regulatory Standards for Preliminary Treatment Plans ensuring that all intake procedures shall include documentation of a preliminary treatment and rehabilitation plan. A group supervision form will be completed and signed by all clinical staff participants acknowledging they have been re-trained in this requirement. Clinical staff that are not present, based on their in-office availability, will review the information with the Clinical Supervisor or Team Leader at their next scheduled individual supervision and will sign the individual supervision log confirming re-training of this requirement. A copy of both the group supervision form and each individual supervision log will be sent to the Clinical Director to confirm that the training occurred. Random chart reviews will be documented in the client record through either the Chart Review service in the EHR or scanned into the client chart. A mock audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will confirm that preliminary treatment plans are being entered as part of the intake assessment documentation. |
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 client records, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in six of seven client records.
Client #1 was admitted July 18, 2022 and was still active at time of inspection. A treatment and rehabilitation plan update was completed on September 13, 2022. A treatment and rehabilitation plan update was due no later than November 13, 2022, however a treatment and rehabilitation plan update did not occur until December 27, 2022.
Client #2 was admitted August 18, 2022 and was still active at the time of inspection. A treatment and rehabilitation plan was developed on August 18, 2022. A treatment and rehabilitation plan update was due no later than October 18, 2022, however a treatment and rehabilitation plan did not occur until October 27, 2022. The next treatment and rehabilitation plan update was due on December 27, 2022, but did not occur until January 23, 2023.
Client #3 was admitted September 7, 2022 and was still active at time of inspection. A treatment and rehabilitation plan was developed on September 7, 2022. A treatment and rehabilitation plan update was due no later than November 7, 2022, however a treatment and rehabilitation plan update did not occur until November 14, 2022.
Client #4 was admitted April 18, 2022 and was discharged on August 11, 2022. A treatment and rehabilitation plan was developed on May 3, 2022. A treatment and rehabilitation plan update was due no later than July 3, 2022, however a treatment and rehabilitation plan update did not occur until July 19, 2022.
Client #5 was admitted February 11, 2022 and was discharged September 6, 2022. A treatment and rehabilitation plan update was done March 29, 2022. A treatment and rehabilitation plan update was due no later than May 29, 2022, however a treatment and rehabilitation plan update did not occur until September 6, 2022.
Client #7 was admitted May 9, 2022 and was discharged November 9, 2022. A treatment and rehabilitation plan was developed on May 9, 2022. A treatment and rehabilitation plan update was due no later than July 9, 2022, however a treatment and rehabilitation plan update was not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will facilitate weekly group staffing/supervision on 2/28/23 and will include a review of the SPHS internal policy and DDAP Regulatory Standards for Treatment Plan updates and related time frames ensuring that treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. A group supervision form will be completed and signed by all clinical staff participants acknowledging they have been re-trained in this requirement. Clinical staff that are not present, based on their in-office availability, will review the information with the Clinical Supervisor or Team Leader at their next scheduled individual supervision and will sign the individual supervision log confirming re-training of this requirement. A copy of both the group supervision form and each individual supervision log will be sent to the Clinical Director to confirm that the training occurred. Clinical staff will be expected to maintain a current list of treatment plan completion and update dates. This list will be reviewed with the clinical supervisor and/or team leader in individual supervision and documented on individual supervision logs. The clinical supervisor and/or their delegate will review treatment plan completion monthly to ensure that all staff are adequately completing these items. Random chart reviews will be documented in the client record through either the Chart Review service in the EHR or scanned into the client chart. A mock audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will confirm that treatment plan updates are occurring as required throughout an individual's treatment. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to shall assure that counseling services are provided according to the individual treatment and rehabilitation plan in seven out of seven client records.
Client# 1 was admitted on July 18, 2022 and was still active at the time of the inspection. A treatment plan update was completed on September 13, 2022 indicating one individual and one group session to occur per week. Individual sessions were not documented for the week of October 30, 2022, as well as the week of November 20, 2022. A group session was not documented for the week of October 23, 2022.
Client #2 was admitted August 18, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on August 18, 2022 indicating one individual session to occur per week. Individual sessions were not documented for the week of September 18, September 25, and October 9, 2022.
Client #3 was admitted September 7, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 7, 2022 indicating one individual session to occur per week, as well as three group sessions to occur per week. Individual sessions were not documented for the weeks of September 18, October 16, October 23, and October 30, 2022. At least three group sessions were not documented for the weeks between September 8, 2022 and October 15, 2022.
Client #4 was admitted April 18, 2022 and discharged August 11, 2022. A comprehensive treatment plan was developed on May 3, 2022 indicating two group sessions to occur per week. Group sessions were not documented for the weeks between May 3, 2022 and June 26, 2022.
Client #5 was admitted February 11, 2022 and discharged September 6, 2022. A comprehensive treatment plan was developed on February 11, 2022 indicating one individual sessions per week, as well as two group sessions per week. Individual sessions were not documented the weeks of February 13, 2022 and March 6, 2022. Group sessions were not documented for the weeks of February 13, 2022 and February 20, 2022. Only one group session was documented for the weeks of February 27, March 6, March 13, and March 20, 2022.
A treatment plan update was completed March 29, 2022 indicating one individual session every two weeks, as well as two group sessions per week. Group sessions were not documented from the weeks between April 2, 2022 through discharge.
Client #6 was admitted February 28, 2022 and discharged September 30, 2022. A treatment plan update was completed March 25, 2022 indicating one individual session per week. No individual sessions were documented the weeks of March 27, April 3, and April 10, 2022.
Client #7 was admitted May 9, 2022 and discharged November 9, 2022. A comprehensive treatment plan was developed May 9, 2022 indicating one individual session per week, as well as three group sessions per week. No individual session was documented the week of June 19, June 26, and July 3, 2022. Only two group sessions were documented the weeks of June 5 and June 19, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will facilitate weekly group staffing/supervision on 2/28/23 and will include a review of the SPHS internal policy and DDAP Regulatory Standards that the project ensures that counseling services are provided according to the individual treatment and rehabilitation plan. A group supervision form will be completed and signed by all clinical staff participants acknowledging they have been re-trained in this requirement. Clinical staff that are not present, based on their in-office availability, will review the information with the Clinical Supervisor or Team Leader at their next scheduled individual supervision and will sign the individual supervision log confirming re-training of this requirement. A copy of both the group supervision form and each individual supervision log will be sent to the Clinical Director to confirm that the training occurred. Clinical staff will be expected to maintain a current list of individual treatment modalities and actively plan for any possible disruptions with the clinical supervisor and/or team leader in individual supervision and documented on individual supervision logs. Clinical supervisor and/or team leader will also be expected to check staff schedules at least monthly to ensure that all no show/cancellation notes have been completed to ensure accurate documentation of these scheduled sessions. Random chart reviews will be documented in the client record through either the Chart Review service in the EHR or scanned into the client chart. A mock audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will confirm that services are provided according to the individual's treatment and rehabilitation plan. |
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 note per the project policy in four of seven client records. The project policy is to complete a case consultation note within ninety days of admission, and then annually thereafter.
Client #1 was admitted July 18, 2022 and was still active at time of inspection. A case consultation note was due no later than October 18, 2022, however a case consultation note was not documented until January 23, 2023.
Client #4 was admitted April 18, 2022 and was discharged on August 11, 2022. A case consultation note was due no later than July 18, 2022, however a case consultation note was not documented until August 8, 2022.
Client #5 was admitted February 11, 2022 and was discharged September 6, 2022. A case consultation note was due no later than May 11, 2022, however a case consultation note was not documented until September 6, 2022.
Client #7 was admitted May 9, 2022 and was discharged November 9, 2022. A case consultation note was due no later than August 9, 2022, however a case consultation note was not documented at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will facilitate weekly group staffing/supervision on 2/28/23 and will include a review of the SPHS internal policy and DDAP Regulatory Standards ensuring that all clients have a case consultation documented in their EHR within 90 days of admission and then annually thereafter. A group supervision form will be completed and signed by all clinical staff participants acknowledging they have been re-trained in this requirement. Clinical staff that are not present, based on their in-office availability, will review the information with the Clinical Supervisor or Team Leader at their next scheduled individual supervision and will sign the individual supervision log confirming re-training of this requirement. A copy of both the group supervision form and each individual supervision log will be sent to the Clinical Director to confirm that the training occurred. During individual supervisions case consultations will be documented by either the clinical supervisor/team leader or the clinician at the time of supervision. Clinical supervisor and/or team leader will also be expected to review case consultation documentation at least monthly to ensure that all required documentation is being completed. Random chart reviews will be documented in the client record through either the Chart Review service in the EHR or scanned into the client chart. A mock audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will confirm that case consultations are being entered into the EHR as required. |