INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 31, 2007 through November 1, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cora Services, Inc. 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 November 27, 2007.
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Plan of Correction
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a complete medical history in four of five records reviewed, #1, 3, 4 and 5. The client's family medical history was missing in four records, #1, 3, 4 and 5. The client's personal medical history was missing in one record reviewed, #3.
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Plan of Correction
The Project Director has ensured that the proper Medical Histiry Form that includes family medical history has been added to the client Intake Packet and Psychosocial Evaluation used by the staff for current and new clients. The Clinical Supervisor will retrain the staff on the proper completion and assessment of the medical data for both client and family by 11/12/07 and will check all current client records to ensure compliance by 12/6/07. |
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
Based on a review of client records, the facility failed to document a complete aftercare plan in two of two records reviewed, #4 and 5. Time frames for aftercare goals were missing.
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Plan of Correction
The Project Director has clarified the Agency policy and procedure for developing aftercare plans, clearly delineating content and timeframe requirements. The Clinical Supervisor will retrain staff on the procedures for properly completing these plans with appropriate clients by 12/6/07. To ensure continuing compliance, the Clinical Supervisor will review these plans with staff as they develop them with terminating clients. |