INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, High Focus Centers 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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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 client records, the facility failed to develop and document an individual treatment and rehabilitation plan with the client in four of seven client records reviewed.Client #1 was admitted on November 4, 2024 and was active at the time of the inspection. There was no documentation, in the record, of an individual and rehabilitation plan being completed at the time of inspection.Client #2 was admitted on November 18, 2024 and was active at the time of the inspection. There was no documentation, in the record, of an individual and rehabilitation plan being completed at the time of inspection.Client #3 was admitted on December 4, 2024 and was active at the time of the inspection. There was no documentation, in the record, of an individual and rehabilitation plan being completed at the time of inspection.Client #5 was admitted on August 27, 2024 and was discharged on November 11, 2024. There was no documentation, in the record, of an individual and rehabilitation plan being completed at the time of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Correction Plan:
1. Policy Review and Revision:
o The facility's current policy regarding the development of individual treatment and rehabilitation plans will be reviewed and revised as necessary to ensure compliance.
o Staff will be required to complete treatment plans within 72 hours of client admission.
2. Staff Training and Implementation:
o All clinical staff responsible for developing treatment plans will receive training on the updated policy and documentation procedures by 02/15/25.
o The training will emphasize the importance of timely treatment plan development and the consequences of non-compliance.
3. Implementation of a Treatment Plan Documentation System:
o The facility will implement a tracking system to monitor treatment plan completion within the required timeframe.
o Alerts and reminders will be set for clinical staff to ensure treatment plans are documented within the first 72 hours of admission.
4. Quality Assurance and Compliance Monitoring:
o The Clinical Director or designated staff will conduct weekly audits of new admissions to verify that treatment plans are completed and documented in a timely manner.
o Any discrepancies found during audits will be addressed immediately, and corrective actions will be taken as necessary.
o Audit findings will be reviewed during monthly staff meetings to ensure ongoing compliance and process improvement.
5. Responsible Staff:
o The Clinical Director will be responsible for ensuring that all corrective actions are implemented effectively and that staff remain compliant with the regulation.
o The Compliance Officer will oversee the audit process and report findings to management.
6. Completion Date:
o Full implementation of this corrective action plan will be completed by 02/28/25, with ongoing monitoring thereafter.
By taking these steps, the facility aims to prevent recurrence of non-compliance and ensure that all treatment and rehabilitation plans are developed and documented with the client within the required timeframe.
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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 client records, the facility failed to ensure all treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of two applicable client records reviewed.Client #4 was admitted on July 12, 2024 and was discharged on December 10, 2024. The individual treatment and rehabilitation plan was completed on July 18, 2024 and the first update was due no later than September 18, 2024; however, the update was completed on September 24, 2024. Additionally, the next treatment plan update was due to be completed no later than November 24, 2024; however, that update was completed on November 28, 2024.Client #6 was admitted on September 23, 2024 and was discharged on December 10, 2024. The individual treatment and rehabilitation plan was completed on September 25, 2024 and the first update was due no later than November 25, 2024; however, the update was completed on December 3, 2024.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Correction Plan:
1. Policy Review and Revision:
o The facility's current policy regarding treatment plan reviews will be reviewed and revised as necessary to ensure compliance with the 60-day update requirement.
o A specific tracking system will be implemented to ensure all treatment plans are updated within the required timeframe.
2. Staff Training and Implementation:
o All clinical staff responsible for treatment plan updates will receive training on the updated policy and tracking system by 2/28/25.
o The training will emphasize the importance of adhering to the regulatory timeframe and the consequences of non-compliance.
3. Implementation of a Treatment Plan Tracking System:
o The facility will implement a digital or manual tracking system to monitor due dates for treatment plan updates.
o Alerts and reminders will be set for clinical staff to complete updates at least one week prior to the due date.
4. Quality Assurance and Compliance Monitoring:
o The Clinical Director or designated staff will conduct monthly audits of treatment plans to ensure compliance with the 60-day review requirement.
o Any discrepancies found during audits will be addressed immediately, and corrective actions will be taken as necessary.
o Audit findings will be reviewed during monthly staff meetings to ensure ongoing compliance and process improvement.
5. Responsible Staff:
o The Clinical Director will be responsible for ensuring that all corrective actions are implemented effectively and that staff remain compliant with the regulation.
o The Compliance Officer will oversee the audit process and report findings to management.
6. Completion Date:
o Full implementation of this corrective action plan will be completed by 03/15/25, with ongoing monitoring thereafter.
By taking these steps, the facility aims to prevent recurrence of non-compliance and ensure that all treatment and rehabilitation plans are reviewed and updated within the required 60-day timeframe.
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