INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 14, 2007- November 15, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alliance Medical Services 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 December 7, 2007.
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Plan of Correction
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. 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 review of the client records it was determined that the facility failed to ensure that the drug and alcohol histories were complete on a consistent basis. The drug and alcohol histories documented were consistently incomplete missing the clients' progression of substance use/abuse relative to the clients' lengths and patterns of use/abuse 7 of 8 client records reviewed, specifically # 1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
The Alliance Medical Services Clinical Committee will meet on Dec. 4, 2007 to review the Drug & Alcohol History portion of the assessment tool in order to restructure the section. The emphasis will be on providing a structure by which the history will clearly show a progression of use, abuse, and dependency by life stage. In doing this, lengths, patterns, and life events will be throughly detailed. The revised tool will be in place by Jan 1, 2007. Both the Project Director and Facility Director will be responsible for these revisions. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. 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 review of the client records it was determined that the facility failed to ensure the documentation of complete personal histories. Personal histories were consistently incomplete relative to family history, recreational history, employment history, educational history, legal history and sexual history in 8 out of 8 client records reviewed.
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Plan of Correction
The Alliance Medical Services Clinical Committee will meet on Dec. 4, 2007 and will review the personal history sections of the assessment tool in order to expand on these areas. The necessary revisions will be made and the tool will be in place by Jan. 1, 2008. The Project Director and Facility Director will be responsible for making these changes. |