INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 3, 2009 licensure renewal inspection. The follow-up inspection was conducted on December 22, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Holcomb Associates, Inc. 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 January 16, 2009.
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Plan of Correction
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on an interview with the facility's clinical supervisor, and based on observation, the facility failed to maintain the confidentiality of the clients' identity.
The findings include:
An interview with the clinical supervisor was conducted on December 22, 2009. The clinical supervisor confirmed the practice of having all clients sign the sign-in sheet upon arrival.
On December 22, 2009 at approximately 1:00 PM, the licensing specialist observed a client sign-in sheet, in the reception area, with the first and last name of a client clearly visible to all who affix their signatures to the sign-in sheet.
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Plan of Correction
The Client Sign-in sheet has been removed from the front reception desk, effective 12/22/09.
The front desk receptionist is provided with a Daily Client Roster. As clients enter the waiting room, their names will be checked off and entered as "Present." The receptionist will then notify the clinician of the client's presence. |
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
At the time of the follow-up review, on December 22,2009, it was not possible for the licensing specialist to determine if the facility followed the original plan of correction and was in compliance due to the fact that treatment plan updates were not yet due to be completed in the current records.
The facility must resubmit the original plan of correction.
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Plan of Correction
D&A chart treatment plans will be updated every 60 days, effective 12/22/09. Clinical Support Staff will remind respective clinicians of upcoming deadlines by notation on the Service Rendered Sheets at the time of the appointments. This will be an on-going process. The Clinical Supervisor will review D&A charts and ensure compliance, effective immediately.
The Clinical Supervisor will review all D&A charts for a three-month period of time, and, if they are found to be in compliance, will review charts randomly on a quarterly basis. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
At the time of the follow-up review, on December 22,2009, it was not possible for the licensing specialist to determine if the facility followed the original plan of correction and was in compliance due to the fact that case consultations were not yet due to be completed in the current records.
The facility must resubmit the original plan of correction.
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Plan of Correction
The Clinical Supervisor will supervise clinicians on a bi-monthly basis, review the respective D&A chart information and clinicians' input, write the necessary bi-montly consultations, and enter into the respective D&A charts, effective immediately. |