INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted June 8-9, 2022, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Alpine Springs Rehabilitation & Recovery Center LLC., was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 seven client charts on June 8, 2022, the facility failed to ensure that the individual treatment and rehabilitation plans were developed with the clients. The clients did not sign their treatment plans in four of seven charts reviewed.
Client #1 was admitted 4/29/2022 and is a current client. The treatment plans dated 5/27/2022 and 6/2/2022 were not signed by the client.
Client #2 was admitted 5/14/2022 and is a current client. The 6/3/2022 treatment plan update was not signed by the client.
Client #3 was admitted 5/16/2022 and is a current client. The treatment plans dated 5/25/2022 and 6/3/2022 were not signed by the client.
Client #6 was admitted 12/24/2021 and discharged 1/14/2022. The treatment plan dated 12/17/2021 was not signed by the client.
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Plan of Correction
Counselors will instruct clients to sign their individual treatment plans same day, once created. Clinical Supervisor will gather a new daily Client Documentation Auditing worksheet that will contain the correct and accurate protocol of all clinical staff when working with cliental, from the Counselors and follow up on clinical charts to ensure accuracy with a weekly summary. In addition to writing a monthly report of the findings and of the plan of action for correction and date of correction. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Seven client records were reviewed on June 8, 2022. Based on the review of client records, the facility failed to document a Treatment Plan Update every 15 days in one of the seven client records.
Client #4 was admitted on June 18, 2021 and discharged July 23, 2021. The client record included Master Treatment Plans dated June 22, 2021 and July 22, 2021. The client's treatment regime was less than 30 days so the review and update was to occur every 15 days. There was no documentation of a Treatment Plan Update every 15 days.
7/6/21
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Plan of Correction
Since day of review, APS has hired two Treatment Coordinators and additional Counseling staff to meet the requirements of Treatment Plan Updates. Counselors will be directly responsible for their client's Treatment Plan Update, and it is the responsibility of the Clinical Supervisor to ensure this process is completed. A treatment plan update will be conducted weekly by counseling staff.
Clinical Supervisor will review Client Documentation Auditing worksheets will contain the correct and accurate daily protocol of all clinical staff when working with cliental, for any inconsistencies and have a correction plan. A treatment plan update will be conducted weekly by counseling staff in the instance of individual duration of treatment, this will be overseen by Clinical Supervisor.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in four out of seven client records reviewed.
Client #1 was admitted 4/29/2022 and is a current client. The client's treatment plan states that the client will attend individual treatment sessions once a week and multiple groups a day. The client chart does not include progress notes for individual counseling sessions for the week of 6/3/2022.
Client #4 was admitted 6/19/2021 and discharged 7/23/2021. The client's treatment plan states that the client will attend individual treatment sessions once a week and multiple groups a day. The client chart does not include progress notes for individual counseling sessions for the weeks of 7/14/2021 and 7/21/2021.
Client #6 was admitted 12/24/2021 and discharged 1/14/2022. The client's treatment plan states that the client will attend individual treatment sessions once a week and multiple groups a day. There are no progress notes for individual counseling sessions in the client chart.
Client #7 was admitted 12/24/2021 and discharged 1/21/2022. The client's treatment plan states that the client will attend individual treatment sessions once a week and multiple groups a day. The client chart does not include progress notes for individual counseling sessions for the week of 12/31/2021.
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Plan of Correction
Since day of review, APS has hired additional Counseling staff and two Treatment Coordinators to staffing, to ensure all documentation is completed in a timely manner. New Client Documentation Auditing Worksheets, which is to ensure that clinical staff completes all correct documentation and follows protocol, are to be completed daily with a weekly report from Clinical Supervisor and compiled into a monthly report. A review of the Client Documentation Audit Worksheet will be reviewed at the daily morning meeting with clinical staff. At the end of the week, if there are any inconsistencies, clinical staff assigned to the client will be notified by Clinical Supervisor to correct documentation before end of the day. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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
Seven client records were reviewed on June 8, 2022. Four client records were reviewed as discharged clients. Four discharged clients required documentation of an aftercare plan. The facility did not document an aftercare plan in client record # 6.
Client # 6 was admitted on December 24, 2021 and was discharged on January 14, 2022. There was no documentation of an aftercare plan.
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Plan of Correction
With additional staffing of Treatment Coordinators to the Clinical Team, this will correct the missed documentation of all client aftercare. Clinical Supervisor will gather a new daily Client Documentation Auditing worksheet, which is to ensure that clinical staff completes all correct documentation and follows protocol. A review of the Client Documentation Audit Worksheet will be reviewed at the daily morning meeting with clinical staff and follow up on clinical charts to ensure accuracy with a weekly summary. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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
Seven client records were reviewed on June 8, 2022. Four client records were reviewed as discharged clients. Four discharged clients required documentation of a discharge summary. The facility did not document a discharge summary in client record # 6.
Client # 6 was admitted on December 24, 2021 and was discharged on January 14, 2022. There was no documentation of a discharge summary.
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Plan of Correction
Treatment Coordinators and Counseling Staff have been hired at each APS facility to ensure accurate documentation of each client. With the additional staffing at both facilities, the Clinical Supervisor will have the ability to devote over 50% of her time to administrative duties which will ensure effortless and accurate clinical responsibilities. With the newly developed "daily" Clinical Documentation Audit this will ensure that important information as discharges, will be documented by the responsible counselor of that client and will be the responsibility of the Clinical Supervisor to conduct a daily review that protocol is being followed. |