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 11, 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, Rehab Management Inc./ Rehab After Work 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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Observations
Based on a review of client records, the facility failed to ensure that treatment plans were reviewed and updated at least every 60 days in five of seven client records reviewed. Client #1 was admitted February 27, 2020 and was active at the time of inspection. A treatment plan update was completed on April 1, 2020 and a treatment plan update was due no later than June 1, 2020. However, the treatment plan update was not completed at the time of inspection. Client #2 was admitted March 4, 2020 and was active at the time of inspection. A comprehensive treatment plan was completed on March 23, 2020 and a treatment plan update was due no later than May 23, 2020. However, the treatment plan update was not completed at the time of inspection. Client # 3 was admitted June 4, 2020 and was active at the time of inspection. A comprehensive treatment plan was completed on June 28, 2020 and a treatment plan update was due no later than August 28, 2020. However, the treatment plan update was not completed at the time of inspection. Client # 4 was admitted August 15, 2018 and was discharged December 25, 2018. A treatment plan update was completed on September 5, 2018 and a treatment plan update was due no later than November 5, 2018. However, the treatment plan update was not completed until December 5, 2018.Client # 5 was admitted December 21, 2018 and was discharged May 13, 2019. A comprehensive treatment plan was completed on January 21, 2019 and a treatment plan update was due no later than March 21, 2019. However, the treatment plan update was not completed at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Supervisor reviewed findings from DDAP audit with Rehab After Work clinicians on September 15, 2020. Treatment planning training was scheduled for September 29, 2020. Clinicians have been provided with compliance handout/binder for Rehab After Work documentation.
2. Supervisor will conduct training on September 29, 2020 and will review and re-train Rehab After Work clinicians on compliance timelines for initial treatment plans and treatment plan updates. Supervisor will also review best practices for measurable and client-centered treatment planning.
3. Supervisor will ask Rehab After Work clinicians on September 29, 2020 to begin reviewing treatment plan alerts in Carelogic at least weekly. They will be asked to place treatment plan update individual sessions in their Carelogic schedules after completion of the initial treatment plan to ensure the update is completed in the appropriate time period.
4. Supervisor will continue to audit charts monthly for each clinician and review any treatment plan issues with clinicians at weekly and biweekly supervisions. Clinicians will have 2 weeks to make any corrections.
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