INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 9 - 10, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, The Children's Service Center of Wyoming Valley 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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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to notify the client of all of their rights. The Patient Bill of Rights form does not include 709.30 (1)(3)(4) in seven of seven client records reviewed on August 9, 2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On August 13, 2018 a review was completed of the Patient Bill of Rights by the Facility Director. At that time, the document was revised to include all regulations found in 709.30. This revised document was reviewed with all staff on August 13, 2018. All staff were provided with a revised version of the agencies Patient Bill of Rights and directed to begin to immediately implement the revised document. In addition, the previous version of the Patient Bill of Rights was removed from our document database and replaced with the revised version. The Facility Director, in the course of his weekly chart reviews, will ensure that the revised version of the Patient Bill of Rights is being utilized by all staff. This concern was corrected on August 13, 2018, but will continue to be monitored by the Facility Director. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
The facility failed to document the support services on the individual treatment and rehabilitation plan in three of seven client records reviewed on August 9, 2018. Client record #1, #3, #5 did not include the support services on the treatment plan.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On August 13, 2018, an in-service was facilitated by the Facility Director and attended by all staff. This provided an opportunity to address the importance of including any proposed support services in a client's Master Treatment Plan. All staff were previously noting the type and importance of these support systems in the client's preliminary treatment plan, as well as throughout the client's progress notes. However, this information was not being presented on the master treatment plan. The facility Director, in the course of his weekly chart reviews, will review all newly created master treatment plans to ensure that support services are being identified and documented on the client's master treatment plan. This concern was corrected on August 13, 2018, but will continue to be monitored by the Facility Director. |