INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20 and 21, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, St. John Vianney Center, a free-standing psychiatric hospital that provides inpatient drug and alcohol activities, 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 October 12, 2007.
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Plan of Correction
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709.123(b)(2) LICENSURE Tx Plan Update
709.123. Treatment and rehabilitation.
(b) Treatment and rehabilitation services.
(2) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen 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 random patient record review, the facility failed to include the status or document the progress that the client had been made (or lack of progress) in achieving the established goals on the prior treatment plan(s) in two of two client records, #1 and 3.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.123(c)(4) LICENSURE Aftercare Plan
709.123. Treatment and rehabilitation.
(c) Client records. 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:
(4) Drug and alcohol aftercare plan, if applicable.
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Observations
Based on random patient record review, the facility failed to include the readmission criteria and the contact person on the aftercare plan in one of one client records reviewed, # 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.123(c)(5) LICENSURE Follow-up information
709.123. Treatment and rehabilitation.
(c) Client records. 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:
(5) Follow-up information.
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Observations
Based on random patient record review, the facility failed to document a follow-up contact was conducted according to program policy and procedure in two of two client records reviewed, # 3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.123(d)(2) LICENSURE Aftercare Policy
709.123. Treatment and rehabilitation.
(d) Client management services.
(2) The project shall develop a written client aftercare policy.
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Observations
Based on a review of administrative documentation, the facility failed to provide a policy and procedure for the development of aftercare plans.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |