INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 10, 2019 licensure renewal inspection. The follow-up inspection was conducted on April 27, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Diakon Lutheran Social Ministries 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 May 16, 2010.
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Plan of Correction
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document goals with time frames in the aftercare plan in two of two client records.
The findings include:
Two client records were reviewed on April 27, 2010. Aftercare plans were required in two client records. The facility did not document goals with time frames in the aftercare plan in client records #1 and 2.
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Plan of Correction
Preparation and submission of this plan of correction is required by the state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
Staff will be re-educated by the Clinical Director on the correct completion of the aftercare plan with emphasis on inclusion of time frames for the completion of goals. This will take place during a staff meeting on May 13, 2010. |