INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 15-16, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pennsylvania Adult and Teen Challenge-Outpatient was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in three out of three applicable client records.
Client # 2 was admitted on 9/30/22 and discharged on 1/17/23. Documentation of written notification of treatment termination was missing from the client chart.
Client # 5 was admitted on 9/12/22 and discharged on 12/7/22. Documentation of written notification of treatment termination was missing from the client chart.
Client # 8 was admitted on 8/30/22 and discharged on 11/21/22. Documentation of written notification of treatment termination was missing from the client chart.
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Plan of Correction
On 03/17/2023, the Clinical Supervisor trained related to need for providing written notification of the reason for a client's termination from treatment. The Clinical Supervisor will provide the clinical team with relevant training related to 709.33 on 03/23/2023. Written notification of involuntary termination will be provided by 3-24-23 for client charts found deficient. The Clinical Supervisor, in coordination with the Quality Assurance team, will conduct monthly audits to ensure clients are provided with written notification when terminated from treatment. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to document that clients had the opportunity to request reconsideration of a decision terminating treatment in three out of three applicable client records.
Client # 2 was admitted on 9/30/22 and discharged on 1/17/23. Documentation of the opportunity to request reconsideration of a decision terminating treatment was missing from the client chart.
Client # 5 was admitted on 9/12/22 and discharged on 12/7/22. Documentation of the opportunity to request reconsideration of a decision terminating treatment was missing from the client chart.
Client # 8 was admitted on 8/30/22 and discharged on 11/21/22. Documentation of the opportunity to request reconsideration of a decision terminating treatment was missing from the client chart.
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Plan of Correction
709.33(b)
On 03/17/2023, the Clinical Supervisor trained related to need for providing a client with opportunity to appeal a decision to terminate treatment. The Clinical Supervisor will provide the clinical team with relevant training related to 709.33 on 03/23/2023. The clients will receive written notification with the option to request reconsideration by 3-24-23 in the form of a client discharge letter. The Clinical Supervisor, in coordination with the Quality Assurance team, will conduct monthly audits to ensure clients are provided an opportunity to appeal a decision to terminate treatment. |
709.91(a)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records and the Intake, Admission, Discharge for All Levels of Care policy, the facility failed to follow its policy, which states all involuntary discharges will be offered referral information, in one out of six applicable records reviewed.
Client # 1 was admitted on 11/29/22 and medically discharged on 1/11/23. Documentation of referral information was missing from this client record pertaining to the medical discharge.
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Plan of Correction
709.91(a)(4)
On 03/17/2023, the Clinical Supervisor was trained related to the need to provide referral information to clients being discharged. On 03/23/2023, the Clinical Supervisor will provide counseling staff with training related to the need to follow internal policy and external regulations related to the need to provide referral documentation to those being discharged from treatment. The Clinical Supervisor, in coordination with Quality Assurance staff, will conduct monthly audits to monitor compliance with 709.91(a)(4). |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document disclosure to the client of criteria for discharge in nine out of nine records reviewed.
Client # 1 was admitted on 11/29/22 and discharged on 1/11/23. Documentation of the disclosure of discharge criteria was missing from the client record.
Client # 2 was admitted on 9/30/22 and discharged on 1/17/23. Documentation of the disclosure of discharge criteria was missing from the client record.
Client # 3 was admitted on 11/23/22 and discharged on 1/24/23. Documentation of the disclosure of discharge criteria was missing from the client record.
Client # 4 was admitted on 8/16/22 and discharged on 12/23/22. Documentation of the disclosure of discharge criteria was missing from the client record.
Client # 5 was admitted on 9/12/22 and discharged on 12/7/22. Documentation of the disclosure of discharge criteria was missing from the client record.
Client # 6 was admitted on 11/30/22 and discharged on 12/25/22. Documentation of the disclosure of discharge criteria was missing from the client record.
Client # 7 was admitted on 8/27/22 and discharged on 11/30/22. Documentation of the disclosure of discharge criteria was missing from the client record.
Client # 8 was admitted on 8/30/22 and discharged on 11/21/22. Documentation of the disclosure of discharge criteria was missing from the client record.
Client # 9 was admitted on 11/30/22 and discharged on 12/30/22. Documentation of the disclosure of discharge criteria was missing from the client record.
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Plan of Correction
709.91(b)(1)
On 03/17/2023, the Clinical Supervisor was trained related to the need for clients to be provided information related to admission and discharge criteria during the orientation process. On 03/17/2023, the Facility Director updated an existing form to ensure appropriate documentation of the client's notification of admission and discharge criteria. On 03/23/2023, the Clinical Supervisor will provide counseling staff with training related to compliance with 709.91(b)(1). The Clinical Supervisor, in coordination with Quality Assurance staff, will conduct monthly audits to ensure compliance with 709.91(b)(1). |
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 a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with a client in one out of nine records reviewed.
Client # 8 was admitted on 8/30/22 and discharged on 11/30/22. There was no master treatment plan documented in this chart.
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Plan of Correction
709.92(a)
On 03/17/2023, the Clinical Supervisor was trained related to the need for completion of client treatment plans. The Clinical Supervisor will provide training to counseling staff on 03/23/2023 related to the need to ensure all client charts have a completed treatment plan. The Clinical Supervisor in coordination with Quality Assurance staff, will conduct monthly audits to ensure compliance with 709.92(a). |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to include the type and frequency of treatment and rehabilitation services in the treatment plan in six out of nine records reviewed.
Client # 2 was admitted on 9/30/22 and discharged on 1/17/23. The treatment plan dated 1/12/23 does not indicate the frequency individual sessions are to be held.
Client # 3 was admitted on 11/23/22 and discharged on 1/24/23. The treatment plan dated 12/20/22 does not indicate the frequency individual sessions are to be held.
Client # 5 was admitted on 9/12/2 and discharged on 12/7/22. The treatment plan dated 10/18/22 does not indicate the frequency individual sessions are to be held.
Client # 7 was admitted on 8/27/22 and discharged on 11/30/22. The treatment plan dated 11/17/22 does not indicate the frequency individual sessions are to be held.
Client # 8 was admitted on 8/30/22 and discharged on 11/21/22. The treatment plan dated 9/22/22 does not indicate the frequency individual sessions or group sessions are to be held.
Client # 9 was admitted on 11/30/22 and discharged on 12/30/22. The treatment plan dated 12/19/22 does not indicate the frequency individual sessions or group sessions are to be held.
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Plan of Correction
709.92(a)(2)
On 03/17/2023, the Clinical Supervisor was trained related to the need for completion of client treatment plans that include treatment type and frequency. The Clinical Supervisor will provide training to counseling staff on 03/23/2023 related to the need to ensure all client charts have a completed treatment plan that includes treatment type and frequncy. The Clinical Supervisor in coordination with Quality Assurance staff, will conduct monthly audits to ensure compliance with 709.92(a)(2). |