INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 25, 2011 initial licensure inspection. The follow-up inspection was conducted on February 23, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Project Transition 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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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to ensure that clients involuntarily terminated from the program was notified in writing of the reason for termination and the right to appeal the decision to terminate.
The findings include:
A plan of correction follow up inspection was conducted on 2/23/2012. One of three client records was that of an involuntarily terminated client. The record did not contain documentation of a termination letter at the time of the inspection.
Client #3 was admitted to the program on 12/5/2011 and involuntarily terminated on 1/11/2012 due to non compliance with treatment. At the time of the inspection, there was no documentation of a letter notifying the client that she was involuntarily terminated.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
Counselors will insure that letters of involuntary discharge will be completed for all clients discharged involuntarily from treatment. Program Director will monitor closed charts monthly to ensure 100% compliance. |
709.93(a)(2) LICENSURE Client records
709.93. 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.
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Observations
Based on a review of client records, the facility failed to ensure that a complete medication history was documented for each client.
The findings included:
Three client records were reviewed during the plan of correction follow up inspection of 2/23/2012. Two of these records were required to include documentation of a complete medication history. One of two client records failed to include documentation of a complete medication history.
Client record # 1- This client was admitted on 12/7/2011 and was last treated on 2/27/2012. The client medication history did not include documentation of dosage and frequency of use of the client's current medications.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
Intake procedure will be reviewed with all clinical staff by 4/1/2012. Counselors will ensure that a complete medical record is completed for each client upon admission. Program Director will monitor open & closed charts monthly to ensure 100% compliance. |