INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4-6, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Organization for Women in Early Recovery (POWER) 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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709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records and a discussion with the clinical supervisor and lead counselor, the facility failed to include verification that work done by the client at the project was an integral part of his treatment and rehabilitation plan.
The findings include:
Four client records were reviewed on December 6, 2012. Two of the four client records, #1 and #2, did not document the work therapy on the treatment plans.
Client #1 was admitted to treatment on 9-24-2012. The treatment plan was completed on 10-27-2012 and did not include verification of the work done by the client at the project.
Client #2 was admitted to treatment on 10-25-2012. The treatment plan was completed on 11-27-2012 and did not include verification of the work done by the client at the project.
The findings were discussed with the clinical supervisor and was not disputed.
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Plan of Correction
The Halfway House Program Manager will provide oversight to ensure the Individual Therapists are instructed to incorporate verification that work done by the client while at the Halfway House is an integral part of the treatment and rehabilitation plan. She will also facilitate the weekly treatment team meetings and periodically include a discussion of how work done by the client is incorporated into the treatment plan. The Program Manager will review treatment plans to ensure work therapy is an integral part of the plan.
The Halfway House Clinical Supervisor will provide instruction to the Individual Therapists to incorporate the work done by clients is incorporated into the treament and rehabilitation plan. She will do periodic chart reviews to ensure work therapy is addressed in the treatment plan and progress notes and will immediately address any issues of non-compliance.
The Halfway House will be in full compliance by 3/6/2013. |