INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 22, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Rehab After Work 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)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to include in the intake and admission process, a drug and alcohol history that included complete details of the amount of use in client record # ' s 1 and 2, frequency of use in client record # ' s 1, 2, and 7, route of administration in client record # ' s 1, 4, and 7, and date of last use in client record # ' s 2 and 7.
Client #1 was admitted on 10/27/2016 and was an active client at time of inspection.
Client #2 was admitted on 11/08/2016 and was an active client at time of inspection.
Client #4 was admitted on 09/12/2016 and was discharged on 01/05/2017.
Client #7 was admitted on 10/07/2016 and was discharged on 01/05/2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Rehab Supervisor did immediate review and training and Supervisor will have ongoing monthly training with Counselor on filling out the complete Client record that includes the completed drug and alcohol history details, frequency of use, route of administration and the date of last use.
2. Rehab Supervisor will do Weekly review of Client records with Counselor(s) and noting deficiencies and corrective actions to assure 100% compliance.
3. Rehab Supervisor has requested that the Counselor make every effort to reach out to these client(s) to make the corrective actions for a complete drug history and document the results by March 22nd, 2017. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document that services were provided consistent with the type and frequency specified in the individual treatment and rehabilitation plans in client record # ' s 1, 3, and 6.
Client #1 was admitted on 10/27/2016 and was an active client at time of inspection. The individual treatment and rehabilitation plan completed on 11/08/2016 specified that the client participate in group therapy 4 times per week. However, the record of service and progress notes for December 2016 and January 2017 reflect that the client participated in a total of 12 group therapy sessions with no documented no shows or cancellations.
Client #3 was admitted on 07/20/2016 and was an active client at time of inspection. The individual treatment and rehabilitation plans completed on 08/01/2016 and 9/20/2016 specified that the client participate in group therapy 4 times per week. However, the record of service and progress notes for September and October 2016 reflect that the client participated in a total of 6 group therapy sessions with no documented no shows or cancellations.
Client #6 was admitted on 11/07/2016 and was discharged on 01/10/2017. The individual treatment and rehabilitation plan completed on 11/17/2016 specified that the client participate in group therapy 4 times per week. However, the record of service and progress notes for from 11/22/2016-12/12/2016 reflect that the client participated in no group therapy sessions with no documented no shows or cancellations.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Rehab Supervisor did immediate training with counselor going over the importance of documenting the frequencies of attendance, no shows and cancellations.
2. Rehab Supervisor will Have weekly review of all records with the counselor going over the completeness of each file tracking the attendance, no shows and cancellations.
3. Rehab Supervisor will do monthly training on the completeness of all client files and looking for the deficiency in tracking attendance with all clients. |