INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Way of Life Blairsville 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on applicable client records reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one record.
Client #6 was admitted on April 7, 2025 and discharged on May 9, 2025. There was no documentation in the client record notifying the client in writing of termination from the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L0333 POC
On 6/10/2025 the clinical staff were retrained on the requirement for 709.33 (a) Notice of termination. All clinical staff were made aware through the re-training that staff will notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project as well as the reason for termination. To ensure continued compliance all client's that are involuntarily discharged from the project, their files will be checked for the notice of termination during monthly chart audits conducted by the Facility Director and the corporate compliance team.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure in two of six applicable records.
The facility policy and procedure indicates a case consultation to occur within fourteen days of intake, then as needed.
Client #3 was admitted on April 1, 2025 and was still active at the time of the inspection. A case consultation was due to occur no later than April 15, 2025, however this was not completed until April 18, 2025.
Client #5 was admitted on April 3, 2025 and discharged April 21, 2025. A case consultation was due to occur no later than April 17, 2025, however this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
L1807 POC
On 6/13/2025 the clinical staff were retrained on 709.53(a)(8) Case Consultation Notes and 709.53 Client records. The staff were retrained on the area of client case consultations that all clients by policy must receive a case consultation within 14 days of intake, and then as needed. To ensure continued compliance the client files will be checked for the 14 - day case consultation from the date of intake during monthly client chart audits completed by the Facility Director and the corporate compliance team.
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