INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9-11, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Summit Academy 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 October 6, 2009.
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Plan of Correction
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709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. 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 document that drug and alcohol histories were completed in accordance with the facility policy of five days from the admission date in six of eight client records.
The findings include:
Eight client records were reviewed on September 10-11, 2009. Drug and alcohol histories completed within five days of admission were required in eight client records. The date that the drug and alcohol histories were completed were not recorded in client records # 1, 3, 5, 6, 7 and 8.
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Plan of Correction
Histories are collected on all clients, including drug/alcohol histories. Drug/Alcohol therapists are scheduled to be re-trained by the Clinical Supervisor October 15, 2009 regarding the imperative nature of recording the dates of completion for the collection of all information included in client histories, in accordance with facility policy of five days from the admission date.
All newly trained staff will be trained on the proper completion of this task as well. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document that personal histories were completed in accordance with the facility policy of five days from the admission date in six of eight client records.
The findings include:
Eight client records were reviewed on September 10-11, 2009. Personal histories completed within five days of admission were required in eight client records. The date that the personal histories were completed was not recorded in client records # 1, 3, 5, 6, 7 and 8.
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Plan of Correction
Histories are collected on all clients, including personal histories. Drug/Alcohol therapists are scheduled to be re-trained by the Clinical Supervisor October 15, 2009 regarding the imperative nature of recording the dates of completion for the collection of all information included in client histories, in accordance with facility policy of five days from the admission date.
All newly trained staff will be trained on the proper completion of this task as well. |