INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Crossroads Counseling , 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 and a plan of correction is due on April 3, 2008.
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Plan of Correction
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the client record review during the onsite licensing inspection held March 6 , 2008, treatment plan updates did not consistently address progress achieved relative to the stated goals of the treatment plan during the reporting period in client records # 2, 4, 5, 6 and 8.
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all treatment planning requirements. We recognize that treatment plan updates need to consistently address client's progress towards meeting their treatment plan goals. Staff will be retrained on treatment planning requirements as well as the required timeframes on 3/25/2008. In addition, supervisors will been re-trained to monitor client treatment plans to assure that they are completed within the proper timeframes and include all of the required information, specifically reviewing the progress on the stated goals of the treatment plans.
The executive director, William Knecht, will provide the training on 3/25/08 and will oversee the clinical supervisors to assure that this is completed.
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709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on the review of client records during the onsite licensing inspection held March 6 , 2008 the facility failed to document complete medication records in one of two applicable client records ( # 7).
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all requirements regarding completion of a client record. All medication is to be documented in the client chart. Staff will be retrained on record keeping requirements (specifically related to medication records) on 3/25/2008. In addition, supervisors will be re-trained to monitor client charts for accuracy and completeness.
The executive director, William Knecht, will provide the training on 3/25/08 and will oversee the clinical supervisors to assure that this is completed.
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