INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 26, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Renewal Treatment, 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.
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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 the review of client records, the facility failed to document intake procedures that included a medical, drug and alcohol and personal history in one of two client records.
The findings include:
Two client records were reviewed on August 26, 2013. The intake documentation was required in two client records. There was no documentation of histories in client record # 1.
Client # 1 was admitted on February 13, 2013 and discharged on June 14, 2013. There was no documentation of a medical, drug and alcohol or personal history in the client record.
The facility director and clinical supervisor were interviewed on August 26, 2013 and did not dispute the findings.
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Plan of Correction
Renewal Treatment Inc. shall document intake procedures that include a medical, drug and alcohol and personal history. The Facility Director and Clinical Supervisor provided training/instruction to the Intake Staff and Counselors in regards to this requirement. The Clinical Supervisor shall maintain oversight of this requirement through supervision of intake procedures and through regular client record reviews.The Facility Director shall maintain compliance with this directive as part of regular supervision meetings and quality assurance reviews. This POC is currently in place. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in one of two client records.
The findings include:
Two client records were reviewed on August 26, 2013. A psychosocial evaluation was required in two client records. There was no documentation of a psychosocial evaluation in client record # 1.
Client # 1 was admitted on February 13, 2013 and discharged on June 14, 2013. There was no documentation of psychosocial evaluation in the client record.
The facility director and clinical supervisor were interviewed on August 26, 2013 and did not dispute the findings.
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Plan of Correction
Renewal Treatment Inc. staff shall document a psychosocial evaluation as required in all client files. The Facility Director and Clinical Supervisor provided training/instruction to the Counselors in regards to this deficiency and this requirement. The Clinical Supervisor shall maintain oversight of this requirement during regular client file reviews and supervision sessions. The Facility Director shall maintain oversight of this POC during supervision meetings and quality assurance auditing. This POC is in place. |