INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Treatment Trends, Inc. 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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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) 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 records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of seven records reviewed.
Client #1 was admitted on August 6, 2024 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for a medical provider; however, the client records indicate two separate contacts with the medical provider on September 25 and September 30, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To address this deficiency, the Clinical Supervisor and Program Director will conduct an audit of all current client records to ensure that informed and voluntary consents are properly documented. This review will be completed by 12/30/24. Charts are audited by the Clinical Supervisor or designee periodically for adherence to the expectation.
Regarding Client #1, who was admitted on 8/6/24, and discharged on 12/6/24, one day after the audit, a release of information for the community partner was not documented due to his unscheduled discharge. A note was placed in his file documenting the error.
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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
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of six applicable client records reviewed.
Client #1 was admitted on August 6, 2024 and was still active at the time of the inspection. A treatment plan was completed on October 3, 2024 and the next update was due no later November 3, 2024; however, it was not completed until November 8, 2024.
Client #3 was admitted on September 10, 2024 and was still active at the time of the inspection. A treatment plan was completed on October 9, 2024 and the next update was due no later November 9, 2024; however, there is no documentation that one was completed.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plans must be reviewed and updated every 30 days. It is the responsibility of the counselor to collaboratively update the treatment plan with the client during their session. The Clinical Supervisor or their designee will periodically audit all current client records to ensure adherence to this requirement.
To address this deficiency, the Clinical Supervisor will conduct a comprehensive audit of all current charts to verify that treatment plans are compliant. Moving forward, all treatment plan update due dates will be discussed during individual supervision sessions between the counselor and the Clinical Supervisor or their designee.
Regarding client #1, his treatment plan was up to date at the time of his discharge.
Regarding client #3, his treatment plan was updated on 12/5/24, immediately following the audit results.
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