INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Rehab Management, Inc./Rehab After Work 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 7 client records, 3 client records did not contain documentation of a preliminary treatment plan.Client #1 was admitted on 6/16/17 and was active at the time of inspection. Client #2 was admitted on 10/5/17 and was active at the time of inspection. Client #3 was admitted on 10/25/17 and was active at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisor will conduct training on April 17th, 2018 and will review and train Rehab counselors in the correct documentation at intake to include the preliminary treatment plan.
Supervisor will request that Rehab counselors review their intakes and assuring that as of April 18th, 2018 they have a preliminary for all new intakes.
Supervisor will review making sure of full compliance of the results on April 24th, 2018 and will review records going forward on a weekly basis showing preliminary treatment plans for each new client. There will be ongoing quarterly training stressing the necessity of timely treatment plans.
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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 7 client records, 6 client records had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.Client #1 was admitted on 6/16/17 and was active at the time of inspection. A treatment plan was completed 7/17/17 and the next update was due no later than 9/17/17. However, the update was not completed until 10/2/17.Client #2 was admitted on 10/2/17 and was active at the time of inspection. A treatment plan was completed 11/1/17 and the next update was due no later than 1/1/18. However, the update was not completed until 1/20/18.Client #3 was admitted on 10/25/17 and was active at the time of inspection. A treatment plan was completed 11/28/17 and the next update was due no later than 1/28/18. However, the update was not completed until 3/5/18.Client #5 was admitted on 8/29/17 and was discharged on 12/6/17. A treatment plan was completed 9/14/17 and the next update was due no later than 11/14/17. However, the update was not completed as of the date of the inspection.Client #6 was admitted on 11/6/17 and was discharged on 2/13/18. A treatment plan was completed 11/7/17 and the next update was due no later than 1/7/18. However, the update was not completed until 1/18/18.Client #7 was admitted on 8/30/17 and was discharged on 3/7/18. A treatment plan was completed 11/3/17 and the next update was due no later than 1/3/18. However, the update was not completed until 1/16/18.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisor will conduct training on April 17th, 2018 and will review and train Rehab counselors in the correct timeliness for treatment plans and treatment plan updates.
Supervisor will request that Rehab counselors review their timelines for treatment plans and assuring that as of April 28th, 2018 they follow the DDAP guidelines in creating and updating treatment plans within the appropriate time period.
Supervisor will review making sure of full compliance of the results on May 1st, 2018 and will review records going forward on a weekly basis showing treatment plans for each client done in a timely fashion. There will be ongoing quarterly training stressing the necessity of treatment plans and timliness.
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709.93(a) 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:
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Observations
Based on a review of 7 client records, the facility failed to provide a complete client record, which is to include follow up information and aftercare plans in 3 client records.Client #4 was admitted on 6/13/17 and was discharged on 3/13/18. The record did not contain documentation of any follow up information as of the date of the inspection.Client #6 was admitted on 8/29/17 and was discharged on 12/6/17. The client record did not contain documentation of any follow up information as of the date of the inspection.Client #7 was admitted on 8/30/17 and was discharged on 3/7/18. The client record did not contain documentation of an aftercare plan 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
Supervisor will conduct training on April 17th, 2018 and will review and train Rehab counselors in the correct documentation at discharge including discharge summary, aftercare plans and also following up with clients after discharging and documenting the follow up.
Supervisor will request that Rehab counselors review their latest discharges and make assuring that as of April 18th, 2018 they have the appropriate discharge summaries, aftercare plans and documented outreach for all new discharges.
Supervisor will review making sure of full compliance of the results on May 1st, 2018 and will review records going forward on a weekly basis showing all discharges with the appropriate documentation that include discharge summary, aftercare plans and follow up documentation. There will be ongoing quarterly training stressing the necessity of discharge documentation.
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