INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 13, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit Opco, Inc.- Allentown 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 17, 2008.
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Plan of Correction
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on the review of client records, the facility failed to obtain a signed consent to treatment form in one of three client records.
The findings include:
Three client records were reviewed on November 12, 2008. A signed consent to treatment form was required in three client records. The facility did not obtain a signed consent to treatment form from the client in record #2.
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Plan of Correction
Consent to treatment form for record #2 completed 11-14-08. The nurse manager will ensure that consent is complete prior to dosing for all clients effective immediately. Charts will be reviewed by Clinical Director within 1 week of intake to ensure record is complete timeframe immediately and ongoing. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on the review of client records, the facility failed to document a physical examination in three of three client records.
The findings include:
Three client records were reviewed on November 12, 2008. Physical examinations were required in three client records. The facility's physician did not document the client's general appearance and the physician's impressions on the physical examination in client records #1, 2 and 3.
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Plan of Correction
Program Director reviewed documentation deficiencies with physician on December 11, 2008 and records of patient # 1, 2 and 3 were updated to comply with regulation. Documentation requirements for physical exams were reviewed with the physician by the Program Director on December 11, 2008. Files will be reviewed by the Program Director on a weekly basis for 1 month, then on a monthly basis for 3 months, then quarterly random reviews.
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