INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 12, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Pottsville 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 December 6, 2009.
|
Plan of Correction
|
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
|
Observations
Based on a review of client records, the facility failed to document individual treatment plans in two of four records.
The findings include:
Six client records were reviewed on November 12, 2009. Individual treatment plans were required in four client records. An individual treatment plan was not documented in client records, #3 and 4.
|
Plan of Correction
On November 18, 2009 The Corporate Clinical Director/Project Director conducted an intensive training on treatment planning. The facility director will provide continued training to all clinical staff on the appropriate completion individualized treatment plans by December 15, 2009. The facility director and corporate compliance office will continue to audit client files to ensure continued compliance in this area. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the type and frequency of services on the individual treatment plan in two of two records.
The findings include:
Six client records were reviewed on November 12, 2009. Individual treatment plans were documented in two client records. The type and frequency of services was not documented on the individual treatment plan in client records, #1 and 2.
|
Plan of Correction
On November 18, 2009 The Corporate Clinical Director/Project Director conducted an intensive training on treatment planning with emphasis on ensuring that type and frequency of services provided is outlined in the treatment plan. The facility director will provide continued training to all clinical staff on the appropriate completion individualized treatment plans by December 15, 2009. The facility director and corporate compliance office will continue to audit client files to ensure continued compliance in this area. |
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.
|
Observations
Based on a review of client records, the facility failed to document proposed support services on the individual treatment plan in two of two records.
The findings include:
Six client records were reviewed on November 12, 2009. Individual treatment plans were documented in two client records. Proposed support services were not documented on the individual treatment plan in client records, #1 and 2.
|
Plan of Correction
On November 18, 2009 The Corporate Clinical Director/Project Director conducted an intensive training on treatment planning with emphasis on ensuring that proposed support services is documented in the treatment plan. The facility director will provide continued training to all clinical staff on the appropriate completion of individualized treatment plans by December 15, 2009. The facility director and corporate compliance office will continue to audit client files to ensure continued compliance in this area |
709.53(a)(2) LICENSURE Medication records
709.53. Client records.
(a) 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:
(2) Medication records.
|
Observations
Based on a review of client records, the facility failed to document complete medication records in one of one record.
The findings include:
Six client records were reviewed on November 12, 2009. Medication records were required in one client record. Client record #1 included documentation that the client was taking Depakote and Cogentin. However, the prescribed dosage of the Depakote and Cogentin was not documented in client record #1.
|
Plan of Correction
On November 19, 2009, The facility director met with medical staff and provided training on required dumentation specific to medication record with emphasis that frequency and dosage of medication is documented in the client's record. The facility director and corporate compliance office will continue to audit client files to ensure continued compliance in this area |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document follow-up information in three of four records.
The findings include:
Six client records were reviewed on November 12, 2009. Documentation of follow-up was required in four client records. Follow-up was not documented in client records #4, 5 and 6.
|
Plan of Correction
On November 18, 2009 The Corporate Clinical Director/Project Director conducted a training on follow-up requirements with specific emphasis at ensuring that follow-up is also conducted on individuals leaving the program against medical advise. The facility director will provide continued training to all clinical staff on the appropriate completion and documentation of follow-up by December 15, 2009. The facility director and corporate compliance office will continue to audit client files to ensure continued compliance in this area. |