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 September 10, 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, Familylinks, Inc 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(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
The facility failed to provide counseling services according to the individual treatment and rehabilitation plan in seven of seven client records.
Client # 1 was to receive two individual counseling sessions per month according to the treatment plan dated February 25, 2020. Client received only one individual counseling session in March and April 2020.
Client # 2 was to receive two individual counseling sessions per month according to the treatment plan dated February 10, 2020 and updates dated April 10 and June 15, 2020. The client received one individual session in April 2020. Client was to receive one time a week individuals sessions according to the treatment plan update dated August 10, 2020. The client zero individual sessions in August 2020.
Client # 3 was to receive one time a week individual counseling session according to the treatment plan dated December 14, 2019. The client received one individual session in December 2019 and January 2020. The client was to receive two individual counseling session a month according to the treatment plan update dated February 13, 2020. The client received one individual session in February 2020. Client was to receive one individual counseling session a month according to the treatment plan update dated April 14, 2020. The client received zero individual sessions in April 2020.
Client # 4 was to receive one time a week individual counseling session according to the treatment plan dated September 25, 2019 and updates dated November 19, 2019, January 19 and March 19, 2020. The client received two individual sessions in November and December 2019, two individual sessions in January 2020, zero individual sessions in March and May 2020 and one individual session is April 2020. Client was discharged on May 19, 2020.
Client # 5 was to receive two individual counseling sessions per month according to the treatment plan dated July 15, 2019 and updates dated September 16 and November 14, 2019. The client received one individual session in July, October, and December 2019. The client received zero individual sessions in September and November 2019 and January 2020. Client was discharged on February 12, 2020.
Client # 6 was to receive one individual counseling session a week according to the treatment plan dated January 16, 2020 and an update dated March 16, 2020. Client received one individual session in February and two individual sessions in March 2020. The client received zero individual sessions in April and May 2020. Client was discharged on May 14, 2020.
Client # 7 was to receive one time a week individual counseling session according to the treatment plan dated October 24, 2019 and updates dated November 1, 2019 and January 14, 2020. The client received one individual session in November 2019. Client received zero individual counseling sessions in December 2019 and January 2020. Client was discharged on January 10, 2020.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Manager will meet with drug and alcohol therapists on 10/13/2020 @ 9am to review results from licensing audit. Therapists will be provided with a copy of regulation 709.52 Treatment and rehabilitation services. Therapists and Program manager will review regulation regarding frequency of sessions outlined in treatment plans and ensure that frequency of sessions is being met and clear and appropriate documentation is enter into EHR system. Therapists will sign off on review of regulation 709.52 Treatment and rehabilitation services.
Effective immediately Program Manager will review each treatment plan/treatment plan update to ensure that frequency of treatment is being implemented as documented an accurately entered in the EHR.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
The facility failed to document follow up information in two of four client records.
Per facility policy, follow up is to be completed at seven days after discharge.
Client # 4 was discharged on May 19, 2020. There was no follow up documented.
Client # 6 was discharged on May 12, 2020. There was no follow up documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Manager will review regulation 709.93 Client Records with drug and alcohol therapist on 10/13/2020 @ 9am. Therapists will sign off on review of regulation and be given a copy.
Alerts have been built into the EHR to prompt therapists to complete aftercare follow ups at 7 days, 30 days and 60 days after discharge. Program Manager will provide therapists with aftercare follow up dates and review each aftercare follow up in EHR. |