INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16, 2013 , by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Home Nursing Agency, Community Services, 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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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in two of three records reviewed. The findings include:Ten client records were reviewed on April 17, 2013. Ten client records had individual treatment plans. Three of the ten comprehensive treatment plans failed to include type and frequency of treatment.Client # 8 was admitted on March 3, 2013. The comprehensive treatment plan was completed on March 20, 2013. The treatment plan did not include the type and frequency of treatment.Client # 9 was admitted on November 21, 2013. The treatment plan was completed on December 11, 2013. The treatment plan did not include the type and frequency of treatment.Client # 10 was admitted March 5, 2013. The comprehensive treatment plan was completed on March 7, 2013. The treatment plan did not include the type and frequency of treatment.This was confirmed by the Clinical Service Manager.
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Plan of Correction
Effective 4-29-13, the frequency of Treatment and Rehabilitation services has been added to all Treatment Plan forms. A monthly chart audit is completed and we will audit for frequency on all treatment plans for 100% compliance.
Clinical Services Manager will address this directly with any staff who show deficiencies in this area in supervision. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document a complete discharge summary that included the patient's services offered upon discharge in two of three patient records.The findings include:Ten patient records were reviewed on April 17, 2013. Three records were reviewed for discharge summaries. Two of three records did not have discharge summaries that included services offered while in treatment.Patient # 2 was admitted on November 19, 2012 and discharged on April 11, 2013. The discharge summary failed to include the services offered during treatment.Patient # 9 was admitted on November 21, 2012 and discharged on March 6, 2013. The discharge summary failed to include the services offered during treatment.This finding was confirmed by the counseling staff on April 17, 2013.
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Plan of Correction
Effective 4-29-13, all Discharge summaries include space for staff to document Services Offered & Level of Care while the individual is in treatment on the discharge form.
Monthly chart audits are completed and we will audit to ensure that this information is completed and present on 100% of the discharge summaries.
Clinical Services Manager will address directly with any staff who remain deficient in this area in supervision. |