INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 12, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on August 9, 2007.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
The facility failed to complete the staff development program policy. This standard was not met by failing to have a time frame for the overall plan and not having a policy for collecting feedback.
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Plan of Correction
The Project Director will author a staff development program policy, including sections regarding time frames and collection of staff feedabck. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
The facility failed to assist the governing body in formulating policy in the current fiscal year. Documentation was not provided for board meeting minutes or board of director approval of the annual goals and objectives.
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Plan of Correction
This had been scheduled for the regular July Board of Directors meeting in order to accurately assess the progress toward completion of the past annual Goals and Objectives. For the future, Project Director has instructed the corporate secretary to annually include the development, review and adoption of annual project goals and objectives on the Board of Directors' agenda with sufficient notice to ensure their timeliness. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The facility failed to complete annual project goals and objectives. Goals and objectives for the current fiscal year were not documented at the time of the site visit.
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Plan of Correction
This had been scheduled for the regular July Board of Directors meeting in order to accurately assess the progress toward completion of the past annual Goals and Objectives and then set appropriate Goals ans Objectives for the current year. For the future, Project Director has instructed the corporate secretary to annually include the development, review and adoption of annual project goals and objectives on the Board of Directors' agenda with sufficient notice to ensure their timeliness. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
The facility failed to complete progress notes in each of the client records reviewed. The progress notes found in each of the client records reviewed did not consistently document information pertaining to the treatment plan and/or lacked an assessment of the clients progress during the sessions.
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Plan of Correction
The clinical supervisors will provide training to all staff regarding the effective and thorough completion of progress notes. Training and monitoring will include addressing progress notes relating to treatment plans and clearly documenting progress of client sessions. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
The facility failed to consistently complete aftercare plans. In one out of two client records reviewed (client record #5) an aftercare plan was missing.
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Plan of Correction
The clinical supervisors will meet with staff to assure all aftercare plans are completed and monitor compliance on an ongoing basis. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
The facility failed to complete the medical assistance program requirements. Treatment plans and treatment plan updates had not been signed by the physician in the client records reviewed.
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Plan of Correction
The facility will take the appropriate steps to assure that all treatment plans and treatment plan updates funded by the Office of Medical Assistance are reviewed and signed by a physician. |