INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 17, 2024, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient 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 four of eight client records reviewed, the facility failed to provide a preliminary treatment plan in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a preliminary treatment plan be completed after the biopsychosocial or second session.
Client # 1 was admitted on December 19, 2023, and was still active at the time of the inspection. The preliminary treatment was due December 22, 2023, but was not completed until February 8, 2024.
Client # 2 was admitted on January 9, 2024, and was still active at the time of the inspection. The preliminary treatment was due January 9, 2024, but was not completed until February 7, 2024.
Client # 3 was admitted on January 4, 2024, and was still active at the time of the inspection. The preliminary treatment was due January 30, 2024, but was not completed until March 6, 2024.
Client # 8 was admitted on July 31, 2023, and was discharged on November 14, 2023. The preliminary treatment was due August 10, 2023, but was not completed until August 15, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will be resposible for re-training clinical staff on current policy associated with preliminary treatment plan development. This training is scheduled to occur during staff meeting on Thursday May 2nd 2024. In addition, Clinincal Supervisor will assure compliance during routine chart audits. |
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 five of seven applicable client records reviewed, the facility failed to provide a comprehensive treatment plan in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a comprehensive treatment plan be completed within thirty days of admission.
Client # 1 was admitted on December 19, 2023, and was still active at the time of the inspection. The comprehensive treatment was due January 19, 2024, but was not completed until March 5, 2024.
Client # 2 was admitted on January 9, 2024, and was still active at the time of the inspection. The comprehensive treatment was due February 9, 2024, but was not completed until March 19, 2024.
Client # 3 was admitted on January 4, 2024, and was still active at the time of the inspection. The comprehensive treatment was due February 4, 2024, but was not completed until March 10, 2024.
Client # 7 was admitted on December 11, 2023, and was discharged on February 7, 2024. The comprehensive treatment was due January 11, 2024, but was not completed until February 1, 2024.
Client # 8 was admitted on July 31, 2023, and was discharged on November 14, 2023. The comprehensive treatment was due August 31, 2023, but was not completed until September 15, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director has reviewed and updated the current policy to reflect current practicies for development of Comprehensive Treatment Plans. The updated will include a timeframe to develop Comprehensive TX Plans within 30 days of the Preliminary Tx Plan. Clinincal Supervisor will be responsibile for training current clinical staff on updated policy. Clinical Supervisor will maintain compliance through routine chart audits. |