INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 8 through 9, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, York Hospital Behavioral Health Services 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 and a plan of correction is due on February 12, 2008.
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Plan of Correction
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711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a January 9, 2008 review of facility policy and client records, the facility failed to document individual treatment plans within the time frame identified in facility policy in two of six records reviewed, #1 and #2. The facility's policy stated the individual treatment plan must be completed by the third session. The individual treatment plan was missing in client record #1 and late in record # 2.
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Plan of Correction
Clinicians at facility 671074 will be reminded of the policy about and the importance of completing the individual treatment plan by the third session. The facility director will implement this plan of correction and monitor for compliance. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a January 9, 2008 review of client records, the facility failed to document support services on aftercare plans in three of three records reviewed, #6, 7 and 8.
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Plan of Correction
Clinicians at facility 671074 will be reminded of the importance of including support services on aftercare plans. The facility director will implement this plan of correction and monitor for compliance. |