This report is a result of an on-site licensure renewal inspection conducted on September 1-2, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mon Yough Community Services, 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 September 25, 2009.
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Plan of Correction
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Observations
Based on a review of client records, the facility failed to document individualized treatment plans in five of seven client records.
The findings include:
Eight client records were reviewed on September 2, 2009. Individualized treatment plans were required in seven client records. The facility did not document individualized treatment plans in client records # 1, 2, 3, 4, and 6. The treatment plans documented in these client records were identical.
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Plan of Correction
Provide training on individualized treatment plans to all clinical staff by MYCS Utilization Review Manager and Supervisor by October 22, 2009. Create a "treatment plan tool" for staff by December 1, 2009. Audit 5 charts a month to monitor compliance to the treatment plan regulation. If after 6 months the audit has maintained 100% compliance audits may decrease to every other month. Begin audits November 1, 2009.
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