This report is a result of an on-site licensure renewal inspection conducted on March 28, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Guidance for Growing, LLC 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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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the 60-day regulatory period as required by Chapter 709 in one of seven client records reviewed.
The findings include:
Seven client records were reviewed on March 28, 2016. Of the seven client records, three required documentation of treatment plan updates within the regulatory timeframe. The facility failed to document a 60-day treatment plan update in client record #1.
Client #1 was admitted into treatment on January 14, 2016 and was still an active client as of the date of the on-site inspection. The comprehensive treatment plan was completed on 01/25/2016 and the next treatment plan update was due to be completed no later than 03/25/2016. However, there was no documentation of a treatment plan update in the client record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will be responsible for auditing files on a monthly basis, checking treatment plan dates to insure that all plans are up-to-date. If a treatment plan update is required, the clinical supervisor will pull the file for an update to be completed. This process will be enacted on 4/13/2016. The file in question was updated and signed by the client on his next visit to treatment (4/18/2016) |