INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 14 - 16, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alcohol and Drug Abuse 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.
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Plan of Correction
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and an interview with the outpatient director, the facility failed to document an aftercare plan in two of two client records.
The findings include:
Three client records were reviewed on February 15, 2012. Per the facility policy, the counselor and client will complete an aftercare plan at the time of discharge for successful completions. An aftercare plan was required in two client records. The facility did not document an aftercare plan in client records # 2 and #3.
In client record # 2, the client was admitted on 9/12/11 and was discharged on 1/11/12. There was no documentation of an aftercare plan.
In client record # 3, the client was admitted on 6/28/11 and was discharged on 1/9/12. There was no documentation of an aftercare plan.
The findings were reviewed with the outpatient director and were not disputed.
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Plan of Correction
The reviewed records were all from a new outpatient counselor who was still figuring out all the paperwork requirements. The Outpatient Supervisor met with staff on 2/15/12 and reviewed the policy and process for aftercare with her. The Outpatient Supervisor will monitor continued compliance through monthly review of discharge files. |