INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pathway to Recovery Counseling and Educational Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Five client records were reviewed on January 5, 2017. Based on this review, the facility failed to include documentation of a drug and/or alcohol history in one of the five client records reviewed. Client # 3 was admitted on September 27,2016 and was still an active client. There was no documentation of a completed drug and alcohol history in the client's record. These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
A meeting was held on January 9, 2017 with all of the counselors. The documentation of the drug and alcohol history was reviewed and the proper procedure was demonstrated. All counselors were able to verbalize their understanding of the proper way to document a drug and alcohol history. The Program Director will be responsible for monitoring the adherence to this requirement by quarterly chart reviews. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Five client records were reviewed on January 5, 2017. Based on this review, the facility failed to review and update treatment and rehabilitation plans every 30 days in five of five records review.Client # 1 was admitted on March 14, 2016. A treatment plan update was completed on October 2, 2016. There was no documentation that the treatment plan up-date due November 2, 2016 was completed. Client # 2 was admitted on August 2, 2016. A treatment plan update was completed on September 19, 2016. There was no documentation that a treatment plan up-date due October 19, 2016 was completed. Client # 3 was admitted on September 27, 2016. A treatment plan update was completed on October 7, 2016. There was no documentation that a treatment plan up-date due November 7, 2016 was completed. Client # 4 was admitted on February 23, 2016. A treatment plan up-date was completed on October 2, 2016. There was no documentation that a treatment plan up-date due November 2, 2016 was completed. Client # 5 was admitted on April 13, 2016. A treatment plan up-date was completed on June 29, 2016. There was no documentation that a treatment plan up-date due July 29, 2016 was completed. These finding were reviewed with facility staff during the licensing process
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Plan of Correction
A meeting was held on January 9, 2017 with all of the counselors. The documentation standards regarding timely completion of a Treatment Plan Review was discussed. All counselors verbalized their knowledge and understanding of this requirement. The Program Director will be responsible for monitoring this compliance by quarterly chart reviews. |