INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Program for Offenders, Inc. 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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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment and rehabilitation plan in four of ten outpatient client records.
The findings include:
Ten outpatient client records were reviewed on May 15, 2015. Ten client records required documentation of a preliminary treatment plan. The facility failed to document a preliminary treatment and rehabilitation plan in client records # 2, 4, 6 and 10.
Client # 2 was admitted into treatment on April 29, 2015. The intake process was completed on April 29, 2015. There was no documentation of a preliminary treatment and rehabilitation plan for client # 2, as of May 15, 2015.
Client # 4 was admitted into treatment on May 1, 2015. The intake process was completed on May 1, 2015. There was no documentation of a preliminary treatment and rehabilitation plan for client # 4, as of May 15, 2015.
Client # 6 was admitted into treatment on April 15, 2015. The intake process was completed on April 15, 2015. There was no documentation of a preliminary treatment and rehabilitation plan for client # 6, as of May 15, 2015.
Client # 10 was admitted into treatment on April 8, 2015. The intake process was completed on April 8, 2015. There was no documentation of a preliminary treatment and rehabilitation plan for client # 10, as of May 15, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff conducting intake sessions shall ensure that there is a Preliminary treatment plan or if client has been stepped down in treatment from within our residential program the last treatment plan prior to that clients discharge submitted for outpatient services. All staff will receive orientation regarding the treatment plan process upon employment. The training will be conducted by the Director of Behavioral Health services or Clinical supervisor. The Director of Behavioral Services will conduct monthly chart audits to assure treatment plans documentation is within the charts in a timely manner. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitation services in seven of ten outpatient client records.
The findings include:
Ten outpatient client records were reviewed on May 15, 2015. Ten client records required documentation of an individual treatment plan including the type and frequency of treatment and rehabilitation services. The facility failed to document an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitation services in client records # 1, 2, 4, 5, 6, 7 and 10.
Client # 1 was admitted into treatment on April 17, 2015. An individual treatment and rehabilitation plan was completed on April 17, 2015. The individual treatment plan for client # 1 did not include the frequency of individual and group counseling sessions.
Client # 2 was admitted into treatment on April 29, 2015. An individual treatment and rehabilitation plan was completed on May 13, 2015. The individual treatment plan for client # 2 did not include the type and frequency of treatment and rehabilitation services.
Client # 4 was admitted into treatment on May 1, 2015. An individual treatment and rehabilitation plan was completed on May 12, 2015. The individual treatment plan for client # 4 did not include the frequency of individual counseling sessions.
Client # 5 was admitted into treatment on April 6, 2015. An individual treatment and rehabilitation plan was completed on April 6, 2015. The individual treatment plan for client # 5 did not include the frequency of individual and group counseling sessions.
Client # 6 was admitted into treatment on April 15, 2015. An individual treatment and rehabilitation plan was completed on April 22, 2015. The individual treatment plan for client # 6 did not include the type and frequency of treatment and rehabilitation services.
Client # 7 was admitted into treatment on April 6, 2015. An individual treatment and rehabilitation plan was completed on April 6, 2015. The individual treatment plan for client # 7 did not include the frequency of individual and group counseling sessions.
Client # 10 was admitted into treatment on April 8, 2015. An individual treatment and rehabilitation plan was completed on April 13, 2015. The individual treatment plan for client # 10 did not include the type and frequency of treatment and rehabilitation services.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and or Director of Behavioral Health Services will provided training regarding the treatment planning process for all new staff during their initial employment orientation.
Current clinical staff will receive information regarding the treatment plan process during clinical staff meeting conducted by the Director of behavior health Services on 6/12/2015
The Director of Behavioral Services will conduct monthly chart audits to assure treatment plans are documented within the charts in a timely manner. All clinical staff will indicate the type of intervention to be provided with the frequency and duration of that intervention. Plans will be updated every 60 days as required
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