INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 January 12, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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, Allied Addiction Recovery, LLC 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(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates at least every 60 days.Client #2 was admitted on May 24, 2020 and is currently an active client. The comprehensive treatment plan was completed on June 9, 2020 and a treatment plan update was documented on August 9, 2020. There was no documentation of treatment plan updates for October and December 2020.Client #3 was admitted on May 3, 2020 and discharged November 18, 2020. The comprehensive treatment plan was completed on June 9, 2020 and a treatment plan update was documented on August 9, 2020. There was no documentation of a treatment plan update for October 2020.Client #4 was admitted on April 12, 2020 and is currently an active client. The comprehensive treatment plan was completed on May 12, 2020. There were no treatment plan updates completed for the months of July and September 2020. There was one treatment plan update dated November 15, 2020.Client #7 was admitted on October 21, 2019 and discharged September 27, 2020. The comprehensive treatment plan was completed on November 16, 2019 treatment plan updates were documented on March 25, May 16 and July 16, 2020. There were no treatment plan updates documented for January and September 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/15/2021 Clinical Director met with clinical staff for training purposes. During this session policy and procedure was read and reviewed concerning clinical documentation due dates, content, and timeliness of MTP and case consults.
Chart reviews will occur weekly by the Clinical Director to monitor progress and adherence. Personal improvement plan developed with therapist to assist in ongoing improvement. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
The facility failed to document case consultations as per the facility policy, which states they will be completed every 60 days along with the treatment plan updates.Client #2 was admitted on May 24, 2020 and is currently an active client. There were no case consultations documented in client record #2.Client #3 was admitted on May 3, 2020 and discharged November 18, 2020. There were no case consultations documented in client record #3.Client #4 was admitted on April 12, 2020 and is currently an active client. There were no case consultations documented in client record #4.Client #7 was admitted on October 21, 2019 and discharged September 27, 2020. The only case consultations documented were on May 16, 2020 and July 16, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/15/2021 Clinical Director met with clinical staff for training purposes. During this session policy and procedure was read and reviewed concerning clinical documentation due dates, content, and timeliness of MTP and case consults.
Chart reviews will occur weekly by the Clinical Director to monitor progress and adherence. Personal improvement plan developed with therapist to assist in ongoing improvement.
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