INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12-13, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Dreamlife 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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709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed types of supportive services in the individual treatment plan in two of four applicable client records. Client #15 was admitted to partial hospitalization on April 29, 2023 and discharged on May 27, 2023. No treatment plans in the record included proposed types of supportive services.Client #16 was admitted to partial hospitalization on April 28, 2023 and discharged on May 26, 2023. No treatment plans in the record included proposed types of supportive services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief of Clinical Care Services will add support services to the front of the treatment plans for the clinicians to check off which are being used or are to be used by the client by 11/1/2023. The Chief of Clinical Care Services will be responsible to audit the charts monthly to ensure that these are being completed. |
709.52(a)(3) LICENSURE Support service type
709.52. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed types of supportive services in the individual treatment plan in six of seven applicable client records. Client #8 was admitted to inpatient on July 17, 2023 and was still active at the time of inspection. No treatment plans in the record included proposed types of supportive services.Client #9 was admitted to inpatient on July 10, 2023 and was still active at the time of inspection. No treatment plans in the record included proposed types of supportive services. Client #10 was admitted to inpatient on July 12, 2023 and was still active at the time of inspection. No treatment plans in the record included proposed types of supportive services.Client #11 was admitted to inpatient on May 10, 2023 and discharged on June 16, 2023. No treatment plans in the record included proposed types of supportive services.Client #12 was admitted to inpatient on January 24, 2023 and discharged on February 28, 2023. No treatment plans in the record included proposed types of supportive services.Client #14 was admitted to inpatient on June 4, 2023 and discharged on June 14, 2023. No treatment plans in the record included proposed types of supportive services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief of Clinical Care Services will add support services to the front of the treatment plans for the clinicians to check off which are being used or are to be used by the client by 11/1/2023.The Chief of Clinical Care Services will be responsible to audit the charts monthly to ensure that these are being completed. |