INITIAL COMMENTS
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This report is a result of an offsite licensure renewal inspection conducted on January 6-7, 2022, and an onsite physical plant inspection completed on February 18, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the off-site inspection, Bradford Recovery 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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709.81(b)(2)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(i) Project policies.
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Observations
Based on a review of seven client records the facility failed to document in all seven client records that all clients are orientated to the project which is to include familiarization with the project ' s policies.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility shall ensure clients are oriented to the project, including project policies, upon admission. Clients will be provided a program handbook (which includes information on project policies, program services offered, hours of operation and facility fee schedule) at admission. The handbook receipt will be signed by the client and scanned into the client EMR file. Facility Admission staff will document receipt of handbook and orientation discussion in the admission note. The client will receive further orientation with Nursing staff, including a facility tour. The nursing orientation will be documented in the nursing admission note. Admission and Nursing Supervisors will complete 5 chart audits (each) monthly to ensure compliance. Outcomes will be reported and discussed at the weekly leadership meeting. |
709.81(b)(2)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of seven client records the facility failed to document in all seven client records that all clients are orientated to the project which is to include familiarization with the hours of operation.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility shall ensure clients are oriented to the project, including hours of operation, upon admission. Clients will be provided a program handbook (which includes information on project policies, program services offered, hours of operation and facility fee schedule) at admission. The handbook receipt will be signed by the client and scanned into the client EMR file. Facility Admission staff will document receipt of handbook and orientation discussion in the admission note. The client will receive further orientation with Nursing staff, including a facility tour. The nursing orientation will be documented in the nursing admission note. Admission and Nursing Supervisors will complete 5 chart audits (each) monthly to ensure compliance. Outcomes will be reported and discussed at the weekly leadership meeting. |
709.81(b)(2)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of seven client records the facility failed to document in all seven client records that all clients are orientated to the project which is to include familiarization with the fee schedule.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility shall ensure clients are oriented to the project, including fee schedule, upon admission. Clients will be provided a program handbook (which includes information on project policies, program services offered, hours of operation and facility fee schedule) at admission. The handbook receipt will be signed by the client and scanned into the client EMR file. Facility Admission staff will document receipt of handbook and orientation discussion in the admission note. The client will receive further orientation with Nursing staff, including a facility tour. The nursing orientation will be documented in the nursing admission note. Admission and Nursing Supervisors will complete 5 chart audits (each) monthly to ensure compliance. Outcomes will be reported and discussed at the weekly leadership meeting. |
709.81(b)(2)(iv) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(iv) Services provided.
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Observations
Based on a review of seven client records the facility failed to document in all seven client records that all clients are orientated to the project which is to include familiarization with the services provided.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility shall ensure clients are oriented to the project, including project services provided, upon admission. Clients will be provided a program handbook (which includes information on project policies, program services offered, hours of operation and facility fee schedule) at admission. The handbook receipt will be signed by the client and scanned into the client EMR file. Facility Admission staff will document receipt of handbook and orientation discussion in the admission note. The client will receive further orientation with Nursing staff, including a facility tour. The nursing orientation will be documented in the nursing admission note. Admission and Nursing Supervisors will complete 5 chart audits (each) monthly to ensure compliance. Outcomes will be reported and discussed at the weekly leadership meeting. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of seven client records, the facility failed to document a psychosocial evaluation in all seven client records as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will provide all Counselors education and training on Psychosocial evaluation documentation requirements as outlined in 709.81(b)(6). The education will be provided by March 15th 2022 and documentation placed in the staff members personnel file. Each Counselor will be required to complete weekly self-audits of their assigned clients. The outcomes will be provided to the Clinical Director on Monday of every week. The Clinical Director will ensure the plan of correction is completed, monitored and within compliance. Outcomes will be reviewed and discussed during individual supervision, as well as the weekly leadership meeting. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of seven partial client records, the facility failed to conduct and document individual counseling sessions at least twice weekly in all seven partial client records reviewed.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from the February 26, 2021 inspection.
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Plan of Correction
The Clinical Director will provide all partial hospitalization counselors further education on program and compliance requirements, including individual counseling, as outlined in (709.82 (d)(1). The refresher education will be provided by March 15th 2022 and provided and documentation placed in the staff members personnel file. All partial hospitalization counselors will sign acknowledgments of understanding individual counseling requirements as outlined in 709.82(d)(1). Partial hospitalization counselors will be required to conduct weekly self-audits. The outcomes will be provided to the Clinical Director on Monday of every week. The Clinical Director will ensure the plan of correction is completed, monitored and within compliance. Outcomes will be reviewed and discussed during individual supervision, as well as the weekly leadership meeting. |
709.62(c)(2)(i) LICENSURE Orientation Proj policies
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(i) Project policies, which include the following:
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Observations
Based on a review of seven client records the facility failed to document in all seven client records that all clients are orientated to the project which is to include familiarization with the project ' s policies.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility shall ensure clients are oriented to the project, including project policies, upon admission. Clients will be provided a program handbook (which includes information on project policies, program services offered, hours of operation and facility fee schedule) at admission. The handbook receipt will be signed by the client and scanned into the client EMR file. Facility Admission staff will document receipt of handbook and orientation discussion in the admission note. The client will receive further orientation with Nursing staff, including a facility tour. The nursing orientation will be documented in the nursing admission note. Admission and Nursing Supervisors will complete 5 chart audits (each) monthly to ensure compliance. Outcomes will be reported and discussed at the weekly leadership meeting. |
709.62(c)(2)(ii) LICENSURE Orientation - Op hours
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of seven client records the facility failed to document in all seven client records that all clients are orientated to the project which is to include familiarization with the hours of operation.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility shall ensure clients are oriented to the project, including hours of operation, upon admission. Clients will be provided a program handbook (which includes information on project policies, program services offered, hours of operation and facility fee schedule) at admission. The handbook receipt will be signed by the client and scanned into the client EMR file. Facility Admission staff will document receipt of handbook and orientation discussion in the admission note. The client will receive further orientation with Nursing staff, including a facility tour. The nursing orientation will be documented in the nursing admission note. Admission and Nursing Supervisors will complete 5 chart audits (each) monthly to ensure compliance. Outcomes will be reported and discussed at the weekly leadership meeting. |
709.62(c)(2)(iii) LICENSURE Orientation - Fee Schedule
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of seven client records the facility failed to document in all seven client records that all clients are orientated to the project which is to include familiarization with the fee schedule.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility shall ensure clients are oriented to the project, including fee schedule, upon admission. Clients will be provided a program handbook (which includes information on project policies, program services offered, hours of operation and facility fee schedule) at admission. The handbook receipt will be signed by the client and scanned into the client EMR file. Facility Admission staff will document receipt of handbook and orientation discussion in the admission note. The client will receive further orientation with Nursing staff, including a facility tour. The nursing orientation will be documented in the nursing admission note. Admission and Nursing Supervisors will complete 5 chart audits (each) monthly to ensure compliance. Outcomes will be reported and discussed at the weekly leadership meeting. |
709.62(c)(2)(iv) LICENSURE Orientation - Services Provided
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(iv) Services provided.
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Observations
Based on a review of seven client records the facility failed to document in all seven client records that all clients are orientated to the project which is to include familiarization with the services provided.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility shall ensure clients are oriented to the project, including project services provided, upon admission. Clients will be provided a program handbook (which includes information on project policies, program services offered, hours of operation and facility fee schedule) at admission. The handbook receipt will be signed by the client and scanned into the client EMR file. Facility Admission staff will document receipt of handbook and orientation discussion in the admission note. The client will receive further orientation with Nursing staff, including a facility tour. The nursing orientation will be documented in the nursing admission note. Admission and Nursing Supervisors will complete 5 chart audits (each) monthly to ensure compliance. Outcomes will be reported and discussed at the weekly leadership meeting. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on a review of seven client records the facility failed to document in all seven client records that all clients are orientated to the project which is to include familiarization with the project ' s policies.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility shall ensure clients are oriented to the project, including project policies, upon admission. Clients will be provided a program handbook (which includes information on project policies, program services offered, hours of operation and facility fee schedule) at admission. The handbook receipt will be signed by the client and scanned into the client EMR file. Facility Admission staff will document receipt of handbook and orientation discussion in the admission note. The client will receive further orientation with Nursing staff, including a facility tour. The nursing orientation will be documented in the nursing admission note. Admission and Nursing Supervisors will complete 5 chart audits (each) monthly to ensure compliance. Outcomes will be reported and discussed at the weekly leadership meeting. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of seven client records the facility failed to document in all seven client records that all clients are orientated to the project which is to include familiarization with the hours of operation.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility shall ensure clients are oriented to the project, including hours of operation, upon admission. Clients will be provided a program handbook (which includes information on project policies, program services offered, hours of operation and facility fee schedule) at admission. The handbook receipt will be signed by the client and scanned into the client EMR file. Facility Admission staff will document receipt of handbook and orientation discussion in the admission note. The client will receive further orientation with Nursing staff, including a facility tour. The nursing orientation will be documented in the nursing admission note. Admission and Nursing Supervisors will complete 5 chart audits (each) monthly to ensure compliance. Outcomes will be reported and discussed at the weekly leadership meeting. |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of seven client records the facility failed to document in all seven client records that all clients are orientated to the project which is to include familiarization with the fee schedule.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility shall ensure clients are oriented to the project, including fee schedule, upon admission. Clients will be provided a program handbook (which includes information on project policies, program services offered, hours of operation and facility fee schedule) at admission. The handbook receipt will be signed by the client and scanned into the client EMR file. Facility Admission staff will document receipt of handbook and orientation discussion in the admission note. The client will receive further orientation with Nursing staff, including a facility tour. The nursing orientation will be documented in the nursing admission note. Admission and Nursing Supervisors will complete 5 chart audits (each) monthly to ensure compliance. Outcomes will be reported and discussed at the weekly leadership meeting. |
709.51(b)(2)(iv) LICENSURE Services Provided
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iv) Services provided.
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Observations
Based on a review of seven client records the facility failed to document in all seven client records that all clients are orientated to the project which is to include familiarization with the services provided.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The facility shall ensure clients are oriented to the project, including project services provided, upon admission. Clients will be provided a program handbook (which includes information on project policies, program services offered, hours of operation and facility fee schedule) at admission. The handbook receipt will be signed by the client and scanned into the client EMR file. Facility Admission staff will document receipt of handbook and orientation discussion in the admission note. The client will receive further orientation with Nursing staff, including a facility tour. The nursing orientation will be documented in the nursing admission note. Admission and Nursing Supervisors will complete 5 chart audits (each) monthly to ensure compliance. Outcomes will be reported and discussed at the weekly leadership meeting. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of seven client records, the facility failed to document a psychosocial evaluation in all seven client records as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will provide all Counselors education and training on Psychosocial evaluation documentation requirements, as outlined in 709.51(b)(6). The education will be provided by March 15th 2022 and documentation placed in the staff members personnel file. Each Counselor will be required to complete weekly self-audits of their assigned clients. The outcomes will be provided to the Clinical Director on Monday of every week. The Clinical Director will ensure the plan of correction is completed, monitored and within compliance. Outcomes will be reviewed and discussed during individual supervision, as well as the weekly leadership meeting. |
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 a review of the facility ' s policy and procedure manual and seven client records, the facility failed to complete and document at least one case consultation prior to discharge in two of three applicable records.
Client #13 was admitted on July 1, 2021 and discharged on August 4, 2021. The client record did not contain documentation of a case consultation.
Client #14 was admitted on July 8, 2021 and discharged on August 5, 2021. The client record did not contain documentation of a case consultation.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
The Clinical Director will provide all counselors education and training on Case Consultation documentation and requirements as outlined in 709.53(a)(8). The training will be completed by March 15th 2022 and documentation placed in each staff members personnel file. Each counselor will be required to complete weekly self- audits of assigned clients. The outcomes will be provided to the Clinical Director on Monday of every week. The Clinical Director will ensure the plan of correction is completed, monitored and within compliance. Outcomes will be reviewed and discussed during individual supervision, as well as the weekly leadership meeting. |