INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard Torre De LA Raza 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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709.33 (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 the decision to involuntarily terminate the client's treatment at the project, which is to include the reason for termination, in one of one applicable client record reviewed.
Client #1 was admitted on April 21, 2025 and was administratively discharged on May 6, 2025. There was no documentation, in the record, indicating the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will notify clients, in writing, of the decision to involuntarily terminate the client's treatment, this notice of termination will include the reason for the termination. Counselors will be re-educated to the administrative discharge policy.
a). Responsible Party:
Counselors and Clinical Supervisor
b). Completion Date: 9/30/2025
Clinical Supervisor will conduct focus review of 90% of clients who are administratively (involuntary) discharged during a 2-month period to ensure compliance with the involuntary termination process.
a). Responsible Party:
Clinical Supervisor,
b). Completion Date: 11/30/2025
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in two of five applicable client records reviewed.
Client #3 was admitted on April 7, 2025 and was discharged on June 24, 2025. A treatment plan update was completed on May 16, 2025 and the next update was due to be completed by June 16, 2025; however, the update was not completed prior to discharge.
Client #4 was admitted on October 28, 2024 and was discharged on January 16, 2025. A treatment plan update was completed on December 9, 2024 and the next update was due to be completed on January 9, 2025; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will ensure that treatment plans are reviewed and updated at least every 30 days, as per regulations and facility policy. Clients whose treatment is less than 30 days will have their treatment plan reviewed and updated at least every 15 days. Clinical Supervisor will re-educate the counselors as to the importance of adhering to the timeframe for the completion of treatment plans.
a). Responsible Party:
Counselors and Clinical Supervisor
b). Completion Date: 9/30/2025
Clinical Supervisor will conduct focus audit of 5 charts per counselor during a 2-month period to ensure compliance with the treatment plan, treatment plan updates regulation and policy.
a). Responsible Party:
Clinical Supervisor
b). Completion Date: 11/30/2025
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