INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 19,2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Carolyn Mottor-Rivera Counseling 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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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the policies and procedures manual, there was no documentation that the project director annually updated and signed the manual.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will ensure that written (and signed) documentation of each annual review (and update) of project policies and procedures will be included at the beginning of the projects policies and procedures manual effective today (on 05/20/2021). |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support services in the treatment plan in two of the two applicable records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will ensure that each treatment plan (developed with the client) shall include written documentation of proposed type of support service effective today (on 05/20/2021). |