INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on Septemeber 18, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Carolyn Mottor-Rivera Counceling 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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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of seven client records on September 18, 2020, the facility failed to develop intake procedures that include documentation of a psychosocial evaluation.Client #1 was admitted on January 30, 2020 and was discharged on July 31, 2020. The facility failed to provide documentation of a psychosocial evaluation.Client #3 was admitted on October 29, 2019 and was discharged on November 15, 2019. The facility failed to provide documentation of a psychosocial evaluation.Client #7 was admitted on December 4, 2019 and was discharged on January 15, 2020. The facility failed to provide documentation of a psychosocial evaluation.This information was reviewed with facility staff during the licensing process.
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Plan of Correction
In response to citation 709.91(b)(6), the director will:
- complete a review of all patients records within 72 hours of admittance into treatment to ensure completion of the documentation of the psychosocial evaluation
- This facility will include documentation of the psychosocial evaluation on each client record
- correction to 709.91(b)(6) will be completed (and placed into effect) today (on 09/28/2020).
- and the clinical director is responsible for compliance of 709.91 (b) (6).
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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 seven client records on September 18, 2020, the facility failed review and update treatment and rehabilitation plans at least every sixty days.Client #1 was admitted on January 30, 2020 and discharged on July 31, 2020. The last documented treatment and rehabilitation plan was dated on June 22, 2020. A treatment and rehabilitation plan update was due on April 20, 2020, but was not documented in the client record.Client #2 was admitted on March 9, 2020 and discharged on July 28, 2020. The last documented treatment and rehabilitation plan was dated on May 4, 2020. A treatment and rehabilitation plan update was due on July 3, 2020, but was not documented in the client record.Client #4 was admitted on February 24, 2020 and discharged on July 31, 2020. The last documented treatment and rehabilitation plan was dated on May 14, 2020. A treatment and rehabilitation plan update was due on July 14, 2020, but was not documented in the client record.Client #5 was admitted on March 5, 2020 and discharged on July 24, 2020. The last documented treatment and rehabilitation plan was dated on May 14, 2020. A treatment and rehabilitation plan update was due on July 14, 2020, but was not documented in the client record.Client #6 was admitted on February 3, 2020 and discharged on August 3, 2020. A treatment and rehabilitation plan was completed on March 10, 2020 and the next treatment and rehabilitation plan was due on May 10, 2020, but was not documented in the client record.This information was reviewed with facility staff during the licensing process.
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Plan of Correction
In response to citation 709.92 (b) the director will:
- effective today (on 09/29/2020) the director will comply with 709.92 (b) policies and procedures that include an emphasis on completion of "review and update" of "treatment and rehabilitation plans" within no later than 60 days as regulated by the Department
- facility will review (and complete) all updated treatment and rehabilitation plans at least every sixty days.
- the director will monitor compliance on a weekly basis, or as needed, to review case management and compliance of treatment plan update procedures to maintain that all subsequent treatment plan updates are completed no later than every sixty days.
- and correction to 709.92 (b) will be placed into effect today (on 09/29/2020).
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