INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 13-14, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northeast Treatment Centers, 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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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records, the facility failed to inform clients of their client rights.
The findings include:
Twelve client records were reviewed on November 14, 2013 for documentation that the clients had been informed of their rights. There was no documentation of clients being advised of these rights in client records # 6, 7, and 8.
Client # 6 was admitted on May 25, 2013. There was no documentation that the client was informed of the their client rights during orientation.
Client # 7 was admitted on May 21, 2013. There was no documentation that the client was informed of the their client rights during orientation.
Client # 8 was admitted on May 4, 2013. There was no documentation that the client was informed of the their client rights during orientation.
The findings were discussed with the clinical supervisor prior to the exit interview.
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Plan of Correction
Program Director met with Clinical Supervisor on November 18, 2013 to review and discuss the requirement to have a Statement of Patient's Rights present in every client's chart. Clinical Supervisor has added the Statement of Patient's Rights to all client's 6, 7 and 8 as of November 18, 2013. Clinical Supervisor will review every chart on a week to week basis in order to ensure the presence of the Statement of Patient's Rights. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a signed consent to treatment during intake procedures.
The findings include:
Twelve client records were reviewed for consent to treatment forms on November 14, 2013. Three out of twelve client records lacked documentation of intake documentation that included consent to treatment, specifically client records # 6, 7, and 8.
Client # 6 was admitted on May 25, 2013; however was no documentation of consent to treatment in the record representing client #6.
Client # 7 was admitted on May 21, 2013; however was no documentation of consent to treatment in the record representing client #7.
Client # 8 was admitted on May 4, 2013; however was no documentation of consent to treatment in the record representing client #8.
The findings were discussed with the clinical supervisor prior to the exit interview.
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Plan of Correction
Program Director met with Clinical Supervisor on November 18, 2013 to review and discuss the requirement to have a Consent to Treatment present in every client's chart. Clinical Supervisor has added the Consent to Treatment to all client's 6, 7 and 8 as of November 18, 2013. Clinical Supervisor will review every chart on a week to week basis in order to ensure the presence of the Consent to Treatment. |