INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 7, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the inspection, Providence Living Treatment Center 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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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
A review of nine client records was conducted on March 7, 2017. Based on this review, the facility failed to document that a copy of the client consent was offered to the client in all nine records.
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
Effective on 3/9/17, consent form for Authorization to release or obtain information will be revised to include below sentence:
"Client accepts/refuses a copy of this Consent form."
(Circle one)
Facility director has implemented this change on 3/9/17 and all current clients have re-signed the new consent form above on 4/7/17.
This corrective action was completed on 4/7/17. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
A review of nine client records was conducted on March 7, 2017. Based on this review, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated every 60 days in four client records.
Client #1 was admitted on August 2, 2016 and still an active client as of the date of this inspection. A treatment plan up-date was due January 26, 2017 but was not completed until February 28, 2017
Client #2 was admitted on September 13, 2016 and still an active client as of the date of this inspection. A treatment plan up-date was due January 26, 2017 but was not completed until February 22, 2017.
Client #5 was admitted on July 7, 2016 and discharged October 6, 2016. A treatment plan up-date was due September 8, 2016. A treatment plan up-date was not documented in the client record.
Client #6 was admitted on July 22, 2016 and discharged October 27, 2016. A treatment plan up-date was due September 27, 2016. A treatment plan up-date was not documented in the client record.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Below are 2 corrective actions that will take effect on 3/13/2017:
1) A full staff training is scheduled on 3/13/2017 at 1:30pm to review procedure Treatment/Rehabilitation Management 709.24 and attendance is mandatory and training signature will be collected. This training will be conducted by facility director. Facility director will mandate the update of treatment plan by responsible counselors every 60 days.
2) A client record checklist is developed to include all treatment services from intake through discharge and all counselors are required to review and update the checklist every 30 days to ensure compliance of client records according to procedure Client Records 709.93. This checklist is included in all current client's chart on 4/7/17.
Above 2 corrective actions are completed on 4/7/17. Proof of signature for staff training on 3/13/17 is collected and secured in file. A checklist is included in all current clients' chart. |