INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 15, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Reading Hospital 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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711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days was submitted and approved by the Department for the May 4, 2023 and the April 16, 2024 annual licensing inspections. Failing to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days was again found to be a deficiency in the April 15, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure ongoing compliance with plans of correction, the Project Director, Facility Director and Clinical Supervisor will meet monthly beginning in May 2025 to review 10 patient charts for items pertaining to plans of correction including but not limited to: Treatment plan updates, Follow-up, and Consents to release. This monthly review will continue for at least 3 months or until 100% compliance is reached. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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 ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in five of five applicable client records reviewed.
Client # 1 was admitted on December 17, 2024 and was active at the time of inspection. The individual treatment plan was completed on January 9, 2025 and the first update was due no later than March 9, 2025, however, the update was not completed until April 6, 2025.
Client # 2 was admitted on October 23, 2024 and was active at the time of inspection. A treatment plan update was completed on January 8, 2025 and the next update was due no later than March 8, 2025; however, the update was not completed until March 27, 2025.
Client # 4 was admitted on April 30, 2024 and was discharged on July 26, 2024. The individual treatment plan was completed on May 7, 2024 and the first update was due no later than July 7, 2024; however, the update was not completed prior to discharge.
Client # 5 was admitted on August 14, 2024 and was discharged on January 12, 2025. The individual treatment plan was completed on August 29, 2024 and the first update was due no later than October 29, 2024; however, the update was not completed prior to discharge.
Client # 7 was admitted on October 23, 2024 and was discharged on April 8, 2025. The individual treatment plan was completed on November 7, 2024 and the first update was due no later than January 7, 2025; however, the update was not completed prior to discharge.
This is a repeat citation from the April 16, 2024 and May 4, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 4/17/25, treatment plans will be reviewed and updated with documentation of goal status (completed, continuing, etc) at least every 60 days. Ten patient charts will be reviewed monthly by the Project Director, Facility Director and Clinical Supervisor to ensure timely completion of treatment plan updates. This monthly review will continue for at least 3 months or until 100% compliance is reached. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in three of three applicable records reviewed.
Client #4 was admitted on April 30, 2024 and was discharged on July 26, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client #5 was admitted on August 14, 2024 and was discharged on January 12, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client #6 was admitted on February 5, 2024 and was discharged on May 13, 2024. There was no follow-up information documented in the record 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
An updated policy was created on 4/29/25 stating that follow up will be completed with all patients who complete therapy or are transferred to other services within 30 days. Follow up will be completed by program staff who will document it in the patient charts. Ten patient charts will be reviewed monthly by the Project Director, Facility Director and Clinical Supervisor to ensure timely documentation of follow-up. This monthly review will continue for at least 3 months or until 100% compliance is reached. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in seven of seven client records reviewed.
In every client record reviewed, there was evidence of disclosures to the client ' s funding source however, there was no consent to release information form signed by the client present in each client record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the Clinical Supervisor will complete consents to release to the funding source with each applicable patient. Ten patient charts will be reviewed monthly by the Project Director, Facility Director and Clinical Supervisor to ensure proper consents are completed. This monthly review will continue for at least 3 months or until 100% compliance is reached. |