INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on April 6, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, The Program for Offenders, 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:
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Plan of Correction
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709.72(a)(5) LICENSURE Activity Notes
709.72. 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:
(5) Activity notes.
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Observations
Based on a review of client records, the facility failed to document activity notes for TLF clients in three of four client records.
Client records were reviewed on April 6, 2021. TLF clients #1, 2 and 3 did not have any documentation of activity notes.
Client #1 was admitted to TLF on November 23, 2020 and is an active client.
Client #2 was admitted to TLF on January 12, 2021 and discharged on January 19, 2021.
Client #3 was admitted to TLF on May 30, 2020 and discharged on June 30, 2020.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 9, 2019 licensing inspection.
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Plan of Correction
Activity notes will be included within the TLF files by either the Case Manager or Intake Specialist to provide documentation regarding what services the client is being referred or admitted to and what services TPFO is providing the client.The Clinical Supervisor/Lead Therapist will be responsible for reviewing records on a consistency basis to ensure that all documentation is being provided to include the above mentioned services. Further the Clinical Director will be working with all staff involved in the TLF process regarding activity notes to ensure that they are being documented in a timely manner within all clients charts who are involved in the TLF. A plan will be executed and in place by 6/30/21 and will be checked on a weekly basis following that date by the above mentioned staff. |