INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 30, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Bucks County Treatment Solutions 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:
|
Plan of Correction
|
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in ten of fourteen client records reviewed.
The facility policy and procedure manual stated the following procedures:
biopsychosocial assessments, which is to include medical histories, is to be completed within three days of admission for all clients.
preliminary treatment plans are to be completed at intake for all clients.
individual treatment and rehabilitation plan is to be completed within 72 hours of admission for all clients.
Client # 4 was admitted to the partial hospitalization activity on March 25, 2024 and was discharged on May 13, 2024. The medical history was done late, per the policy, as it was completed on May 29, 2024. Additionally, the preliminary treatment plan was late, per the policy, as it was completed on April 2, 2024. Also, the individual treatment and rehabilitation plan was done late, per the policy, as it was completed on April 2, 2024.
Client # 5 was admitted to the partial hospitalization activity on April 18, 2024 and was discharged on May 14, 2024. The medical history was done late, per the policy, as it was completed on April 24, 2024. Additionally, the preliminary treatment plan was done late, per the policy, as it was completed on April 24, 2024. Also, the individual treatment and rehabilitation plan was done late, per the policy, as it was completed on April 24, 2024.
Client # 6 was admitted to the partial hospitalization activity on January 24, 2024 and was discharged on March 11, 2024. The preliminary treatment plan was done late, per the policy, as it was completed on January 30, 2024. Additionally, the individual treatment and rehabilitation plan was done late, per the policy, as it was completed on February 6, 2024.
Client # 7 was admitted to the partial hospitalization activity on January 15, 2024 and was discharged on February 20, 2024. The medical history was done late, per the policy, as it was completed on February 7, 2024.
Client # 8 was admitted to the outpatient activity on May 13, 2024 and was still active at the time of the inspection. The medical history was done late, per the policy, as it was completed on May 29, 2024. Additionally, the individual treatment and rehabilitation plan was done late, per the policy, as it was completed on May 23, 2024.
Client # 9 was admitted to the outpatient activity on May 14, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was done late, per the policy, as it was completed on May 22, 2024.
Client # 11 was admitted to the outpatient activity on March 11, 2024 and was discharged on April 22, 2024. The individual treatment and rehabilitation plan was done late, per the policy, as it was completed on March 18, 2024.
Client # 12 was admitted to the outpatient activity on February 20, 2024 and was discharged on April 22, 2024. The individual treatment and rehabilitation plan was done late, per the policy, as it was completed on March 5, 2024.
Client # 13 was admitted to the outpatient activity on April 5, 2024 and was discharged on July 19, 2024. The medical history was done late, per the policy, as it was completed on April 24, 2024.
Client # 14 was admitted to the outpatient activity on May 20, 2024 and was discharged on July 9, 2024. The preliminary treatment plan was done late, per the policy, as it was completed on May 29, 2024. Additionally, the individual treatment and rehabilitation plan was done late, per the policy, as it was completed on May 29, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The electronic medical record (EMR) system has been revised to automatically fill in all intake forms at the time of admission.
The biopsychosocial assessment has been modified to incorporate the client's medical history.
The Behavioral Health Technician (BHT) will ensure that all forms required at admission are completed. This will serve as a reminder for counselors to finalize the necessary assessments and treatment plans within the stipulated timeframe.
The Clinical Director will examine the charts of newly admitted clients within 48 hours to verify that all required assessments have been conducted. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on consent to release information forms in four of fourteen client records reviewed.
Client # 4 was admitted to the partial hospitalization activity on March 25, 2024 and was discharged on May 13, 2024. There was a release of information form, in the record, signed and dated by the client on March 25, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 5 was admitted to the partial hospitalization activity on April 18, 2024 and was discharged on May 14, 2024. There was a release of information form, in the record, signed and dated by the client on April 19, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 8 was admitted to the outpatient activity on May 13, 2024 and was still active at the time of the inspection. There was a release of information form, in the record, signed and dated by the client on March 25, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 9 was admitted to the outpatient activity on May 14, 2024 and was still active at the time of the inspection. There was a release of information form, in the record, signed and dated by the client on April 19, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Director will conduct a training session with the staff to ensure a thorough understanding of the correct procedures for obtaining consent.
The clinical director is responsible for auditing the charts of new clients within 72 hours of their admission to verify that the consent forms have been accurately recorded. Additionally, the clinical director will conduct weekly audits of all charts, which will include a thorough review of all consent forms for precision. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure clients admitted to the partial hospitalization program received individual counseling services at least twice weekly in four of seven applicable client records reviewed.
Client # 4 was admitted to the partial hospitalization activity on March 25, 2024 and was discharged on May 13, 2024. The record of service and progress notes indicated that individual counseling sessions occurred one time per week during the weeks of March 31, 2024 through April 26, 2024.
Client # 5 was admitted to the partial hospitalization activity on April 18, 2024 and was discharged on May 14, 2024. . The record of service and progress notes indicated that individual counseling sessions occurred one time per week during the weeks of April 21, 2024 through May 4, 2024.
Client # 6 was admitted to the partial hospitalization activity on January 24, 2024 and was discharged on March 11, 2024. The record of service and progress notes indicated that individual counseling sessions occurred one time per week during the weeks of February 11, 2024 through February 22. 2024.
Client # 7 was admitted to the partial hospitalization activity on January 15, 2024 and was discharged on February 20, 2024. The record of service and progress notes indicated that individual counseling sessions occurred one time per week during the week of February 4, 2024 through February 10, 2024. Additionally, there were no individual counseling sessions provided to the client during the week of February 11, 2024 through February 17. 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Director will evaluate the policy in conjunction with the clinical team and review the team's schedule to ensure that all clients receive attention in compliance with regulations. The Clinical Director will also ensure that the necessary sessions are scheduled according to the level of care required.
Furthermore, the clinical director will perform weekly reviews of all patient charts, ensuring that the number of sessions aligns with the designated level of care. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
|
Observations
Based on a review of client records, the facility failed to ensure individual treatment and rehabilitation plans are developed with the client in seven of seven applicable client records reviewed.
Client # 8 was admitted to the outpatient activity on May 13, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 23, 2024; however, there was no documentation indicating the treatment plan was completed with the client.
Client # 9 was admitted to the outpatient activity on May 14, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 22, 2024; however, there was no documentation indicating the treatment plan was completed with the client.
Client #10 was admitted to the outpatient activity on April 2, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed in April, 2024; however, there was no documentation indicating the treatment plan was completed with the client.
Client # 11 was admitted to the outpatient activity on March 11, 2024 and was discharged on April 22, 2024. The individual treatment and rehabilitation plan was completed on March 18, 2024; however, there was no documentation indicating the treatment plan was completed with the client.
Client # 12 was admitted to the outpatient activity on February 20, 2024 and was discharged on April 22, 2024. The individual treatment and rehabilitation plan was completed on March 5, 2024; however, there was no documentation indicating the treatment plan was completed with the client.
Client # 13 was admitted to the outpatient activity on April 5, 2024 and was discharged on July 19, 2024. The individual treatment and rehabilitation plan was completed in April, 2024; however, there was no documentation indicating the treatment plan was completed with the client.
Client # 14 was admitted to the outpatient activity on May 20, 2024 and was discharged on July 9, 2024. The individual treatment and rehabilitation plan was completed on May 29, 2024; however, there was no documentation indicating the treatment plan was completed with the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Director will oversee training sessions for staff concerning treatment planning. Counselors are required to meet with each client whenever there is a change in the level of care and/or discharge, during which they will review the revised treatment plan, and the client will provide their signature to confirm the review of the treatment plan. Additionally, the Clinical Director will conduct weekly chart audits to verify that the treatment plan is current and has been signed by the client to acknowledge any updates made. |