INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 1, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Care Center dba SPHS Care 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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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of outpatient client records, the facility failed to document a preliminary treatment plan in two out of two applicable records.
Client #1 was admitted on June 8, 2022 and was still active at the time of the inspection.
Client #7 was admitted on June 27, 2022 and discharged on December 28, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will facilitate weekly group staffing/supervision on 2/28/23 and will include a review of the SPHS internal policy and DDAP Regulatory Standards for Preliminary Treatment Plans ensuring that all intake procedures shall include documentation of a preliminary treatment and rehabilitation plan. A group supervision form will be completed and signed by all clinical staff participants acknowledging they have been re-trained in this requirement. Clinical staff that are not present, based on their in-office availability, will review the information with the Clinical Supervisor or Team Leader at their next scheduled individual supervision and will sign the individual supervision log confirming re-training of this requirement. A copy of both the group supervision form and each individual supervision log will be sent to the Clinical Director to confirm that the training occurred. Random chart reviews will be documented in the client record through either the Chart Review service in the EHR or scanned into the client chart. A mock audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will confirm that preliminary treatment plans are being entered as part of the intake assessment documentation. |
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 outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in seven out of seven records reviewed.
Client #1 was admitted on June 8, 2022 and was still active at the time of the inspection. A treatment plan was completed on July 13, 2022 and the next update was due no later than September 13, 2022; however, the update was completed on September 27, 2022. The next update was due on November 27, 2022; however, it was completed on November 28, 2022. The next update was due on January 28, 2023; however, it was completed on February 1, 2023.
Client #2 was admitted on June 29, 2022 and was still active at the time of the inspection. A treatment plan was completed on June 29, 2022 and the next update was due no later than August 29, 2022; however, it was not completed until September 2, 2022.
Client #3 was admitted on May 31, 2022 and was still active at the time of the inspection. A treatment plan update was completed on July 21, 2022 and the next update was due no later than September 21, 2022; however, the next update was completed on September 29, 2022. The next update was due on November 29, 2022; however, it was completed on December 8, 2022.
Client #4 was admitted on February 3, 2022 and discharged on August 15, 2022. A treatment plan update was completed on March 30, 2022 and the next update was due no later than May 30, 2022; however, it was completed on August 15, 2022.
Client #5 was admitted on January 28, 2022 and discharged on September 2, 2022. A treatment plan update was completed on March 18, 2022 and the next update was due no later than May 18, 2022; however, it was completed on June 10, 2022. The next update was due no later than August 10, 2022; however, it was completed on September 2, 2022.
Client #6 was admitted on February 22, 2022 and discharged on September 16, 2022. A treatment plan update was completed on May 17, 2022 and the next update was due no later than July 17, 2022; however, it was not completed until September 16, 2022.
Client #7 was admitted on June 27, 2022 and discharged on December 28, 2022. A treatment plan update was completed on September 21, 2022 and the next update was due no later than November 21, 2022; however, it was not completed until November 23, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will facilitate weekly group staffing/supervision on 2/28/23 and will include a review of the SPHS internal policy and DDAP Regulatory Standards for Treatment Plan updates and related time frames ensuring that treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. A group supervision form will be completed and signed by all clinical staff participants acknowledging they have been re-trained in this requirement. Clinical staff that are not present, based on their in-office availability, will review the information with the Clinical Supervisor or Team Leader at their next scheduled individual supervision and will sign the individual supervision log confirming re-training of this requirement. A copy of both the group supervision form and each individual supervision log will be sent to the Clinical Director to confirm that the training occurred. Clinical staff will be expected to maintain a current list of treatment plan completion and update dates. This list will be reviewed with the clinical supervisor and/or team leader in individual supervision and documented on individual supervision logs. The clinical supervisor and/or their delegate will review treatment plan completion monthly to ensure that all staff are adequately completing these items. Random chart reviews will be documented in the client record through either the Chart Review service in the EHR or scanned into the client chart. A mock audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will confirm that treatment plan updates are occurring as required throughout an individual's treatment. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in six out of seven records received.
Client #1 was admitted on June 8, 2022 and was still active at the time of the inspection. A treatment plan update dated September 27, 2022 indicated individual sessions twice a month. In October and November 2022, the client received one counseling session each month on October 10, 2022 and November 23, 2022.
Client #2 was admitted on June 29, 2022 and was still active at the time of the inspection. A treatment plan update dated October 27, 2022 indicated individual sessions one time per month. The client had zero individual sessions in November 2022.
Client #3 was admitted on May 31, 2022 and was still active at the time of the inspection. A treatment plan update dated September 29, 2022 indicated individual sessions one time per week. The client did not have any individual sessions the week of October 16-22, 2022 and during the month of November 2022.
Client #4 was admitted on February 3, 2022 and discharged on August 15, 2022. A treatment plan update dated February 3, 2022 indicated weekly individual sessions. The client had zero individual sessions in March and April 2022.
Client #5 was admitted on January 28, 2022 and discharged on September 2, 2022. A treatment plan dated January 28, 2022 indicated weekly individual sessions. In February 2022, the client received one individual session on February 18, 2022. A treatment plan update dated March 18, 2022 indicated one individual session every other week. The client did not have any individual sessions between April 30, 2022 - May 26, 2022.
Client #7 was admitted on June 27, 2022 and discharged on December 28, 2022. A treatment plan dated July 22, 2022 indicated individual sessions weekly. The client did not receive any individual sessions during the weeks of July 24-30 and July 31-August 6, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will facilitate weekly group staffing/supervision on 2/28/23 and will include a review of the SPHS internal policy and DDAP Regulatory Standards that the project ensures that counseling services are provided according to the individual treatment and rehabilitation plan. A group supervision form will be completed and signed by all clinical staff participants acknowledging they have been re-trained in this requirement. Clinical staff that are not present, based on their in-office availability, will review the information with the Clinical Supervisor or Team Leader at their next scheduled individual supervision and will sign the individual supervision log confirming re-training of this requirement. A copy of both the group supervision form and each individual supervision log will be sent to the Clinical Director to confirm that the training occurred. Clinical staff will be expected to maintain a current list of individual treatment modalities and actively plan for any possible disruptions with the clinical supervisor and/or team leader in individual supervision and documented on individual supervision logs. Clinical supervisor and/or team leader will also be expected to check staff schedules at least monthly to ensure that all no show/cancellation notes have been completed to ensure accurate documentation of these scheduled sessions. Random chart reviews will be documented in the client record through either the Chart Review service in the EHR or scanned into the client chart. A mock audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will confirm that services are provided according to the individual's treatment and rehabilitation plan. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of outpatient client records, the facility failed to document case consultations according to the facility's policy and procedures manual in four out of seven records reviewed. The policy and procedures manual indicated a case consultation in the first ninety days and yearly thereafter.
Client #1 was admitted on June 8, 2022 and was still active at the time. A case consult was due on September 8, 2022; however, it was not completed until December 27, 2022.
Client #4 was admitted on February 3, 2022 and discharged on August 15, 2022. A case consult was due on May 3, 2022; however, it was not completed until August 15, 2022.
Client #5 was admitted on January 28, 2022 and discharged on September 2, 2022. A case consult was due on April 28, 2022; however, it was not completed until September 2, 2022.
Client #6 was admitted on February 22, 2022 and discharged on September 16, 2022. A case consult was due on May 22, 2022; however, it was not completed until September 16, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will facilitate weekly group staffing/supervision on 2/28/23 and will include a review of the SPHS internal policy and DDAP Regulatory Standards ensuring that all clients have a case consultation documented in their EHR within 90 days of admission and then annually thereafter. A group supervision form will be completed and signed by all clinical staff participants acknowledging they have been re-trained in this requirement. Clinical staff that are not present, based on their in-office availability, will review the information with the Clinical Supervisor or Team Leader at their next scheduled individual supervision and will sign the individual supervision log confirming re-training of this requirement. A copy of both the group supervision form and each individual supervision log will be sent to the Clinical Director to confirm that the training occurred. During individual supervisions case consultations will be documented by either the clinical supervisor/team leader or the clinician at the time of supervision. Clinical supervisor and/or team leader will also be expected to review case consultation documentation at least monthly to ensure that all required documentation is being completed. Random chart reviews will be documented in the client record through either the Chart Review service in the EHR or scanned into the client chart. A mock audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will confirm that case consultations are being entered into the EHR as required. |