INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 7, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Montgomery County Outpatient 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 and a plan of correction is due on June 9, 2009.
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Plan of Correction
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709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan in two of four client records.
Findings:
Seven client records were reviewed on May 7, 2009. An individual treatment and rehabilitation plans was required in four client records. The facility did not document an individual treatment plan within the stated timeframe of the project ' s policy and procedures manual for client records # 2 and 4.
The project ' s policy and procedures manual states, individual treatment and rehabilitation plans will be completed within 30 days from admission.
Client record # 2 admission date 02/05/2009, but the treatment plan was not documented until 03/16/2009.
Client record # 4 admission date 03/05/2009, but the treatment plan was not documented until 04/13/2009.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan to include short and long term goals in two of four client records.
Findings:
Seven client records were reviewed on May 7, 2009. An individual treatment plan with short and long term goals was required in four client records. The facility did not document an individual treatment plan to include short and long term goals in client records # 1 and 2.
The treatment plans documented in client records # 1 and 2 contained the same short and long term goals.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 treatment plans to include proposed types of supportive services in two of four client records.
Findings:
Seven client records were reviewed on May 7, 2009. Treatment plans with proposed types of supportive services were required in four client records. The facility did not document treatment plans to include proposed types of supportive services in client records # 3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Based on a review of client records, the facility failed to document a treatment plan update in one of two client records.
Findings:
Seven client records were reviewed on May 7, 2009. Treatment plan updates were reviewed in two client records. The facility did not document a treatment plan update to include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan in client record # 3
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of three client records.
Seven client records were reviewed on May 7, 2009. Follow-up information was required in three client records. The facility did not document follow-up information to include the date follow-up was completed in client records # 5, 6 and 7.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |