INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on July 29 & 30, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lebanon Comprehensive Treatment Center 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 document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in two out of two applicable records reviewed. The facility ' s policy and procedures manual states that the comprehensive treatment plan is completed within 30 days of the admission.
Client #2 was admitted on January 3, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 3, 2024; however, it was not completed until February 6, 2024.
Client #4 was admitted on March 25, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 25, 2024; however, it was not completed until April 26, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Comprehensive treatment plan due dates were reviewed with staff (7/31/2024). Clinical supervisor is monitoring new patients by completing chart reviews on all intake charts via the Quality Record Review Process. Clinical supervisor will monitor clinical staff's comprehensive treatment plans to ensure they are signed and completed within 30 days of admission. Clinical supervisor will document in meetings and individual supervisions of any treatment plan signatures coming up to ensure placed on patients accordingly. |
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 document treatment plan updates within the regulatory timeframe in four out of seven records reviewed.
Client #2 was admitted on January 3, 2024 and was still active at the time of the inspection. A treatment plan was completed on April 22, 2024 and the next update was due no later than June 22, 2024; however, it was not completed until July 1, 2024.
Client #4 was admitted on March 25, 2024 and was still active at the time of the inspection. A treatment plan was completed on May 18, 2024 and the next update was due no later than July 18, 2024; however, it was not completed until July 25, 2024.
Client #5 was admitted on March 12, 2015 and was still active at the time of the inspection. A treatment plan was completed on January 20, 2024 and the next update was due no later than May 20, 2024; however, it was not completed until May 28, 2024.
Client #6 was admitted on January 4, 2021 and was still active at the time of the inspection. A treatment plan was completed on December 12, 2023 and the next update was due no later than April 12, 2024; however, it was not completed until April 26, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan due dates were reviewed with staff (7/31/2024). Clinical supervisor will monitor clinical staff's treatment plans by utilizing the Services Due Report to ensure they are signed and completed within appropriate timeframes. Clinical Supervisor will also monitor progress on this goal via the Quality Record Review Process. Clinical supervisor will document in meetings and individual supervisions of any treatment plan signatures coming up to ensure timely completions. Policy will be reviewed to see if any signature adjustments can be made. |