INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, TrueNorth Wellness Services 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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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of the facility's administrative documentation, the facility failed to provide verification of a written agreement with a licensed hospital or physician, for 24 hour emergency medical coverage.
The findings include:
The administrative documents were reviewed on July 24, 2013. The facility was unable to provide a written agreement with a licensed hospital or physician for 24 hour emergency medical coverage.
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Plan of Correction
The Facilities Director is in the process of drafting a letter of agreement to the local hospital for 24 hour medical coverage. The letter should be finished and sent by 30 August 2013. The Facilities Director will follow up with the process through the month of September until there is a signed agreement in place. This agreement will have our new name reflected in the contract.
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of one client record.
The findings include:
Three discharged client records were reviewed on July 24, 2013. One of the three client records reviewed represented a client who was involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 3.
Client # 3 was involuntarily terminated from the project on March 7, 2013. There was no documentation of a written notification provided to the client upon termination.
The clinical supervisor confirmed the findings.
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Plan of Correction
The Program Director drafted and sent a letter of discharge for this client on July 31, 2013. As of August 9, 2013, the copy is now scanned into his chart for any future review. |
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 the proposed type of support services.
The findings include:
Five client records were reviewed for treatment plans on July 24, 2013. Three out of five client records lacked documentation of a treatment plan that included the proposed type of support services, specifically client records # 2, 3, and 5.
The treatment plan for client #2 was completed on April 11, 2013 and did not include the proposed type of support services.
The treatment plan for client #3 was completed on February 12, 2013 and did not include the proposed type of support services.
The treatment plan for client #5 was completed on April 30, 2013 and did not include the proposed type of support services.
The findings were discussed with the clinical supervisor.
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Plan of Correction
The Program Director will be planning a treatment team meeting during the month of September to document the findings of this inspection. During that meeting,clients names will be given to the appropriate clinician to document support services in the NOTE section of the EMR - as we can not alter existing documents. The Program Director will check by the end of September that this was completed.
To make sure that this is documented appropriately for future reference, the Program Director will be meeting with the EMR administrator to add a section in the EMR to document support services right on the treatment plan. This will be completed by October 30, 2013.
The Program Director will be monitoring Treatment Plans during the first 3 months starting in October, weekly, to ensure that this is being completed. This standard will then be monitored monthly after that to ensure compliance. |