This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 24 - 25, 2011 licensure renewal inspection. The follow-up inspection was conducted on February 23, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Innovative Recovery Solutions, 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 March 28, 2011.
|
Plan of Correction
|
Observations
Based on a review of client records and an interview with the facility director, the facility failed to document that an individual treatment and rehabilitation plan was developed with the client in two of four client records.
The findings include:
Four client records were reviewed on February 23, 2011. Four client records required the completion of an individual treatment and rehabilitation plan. Per regulation, an individual treatment and rehabilitation plan shall be developed with a client. Per agency policy, the individual treatment plan will be developed with the client by the third individual session. The facility failed to document that an individual treatment and rehabilitation plan was developed with the client in client records # 3 and 4.
Client # 3 was admitted into treatment on October 14, 2010. The individual treatment plan was due to be completed no later than the third session, on November 1, 2011. There was no documentation of an individual treatment plan in client record # 3, at the time of the review on February 23, 2011.
Client # 4 was admitted into treatment on October 14, 2010. The individual treatment plan was due to be completed no later than the third session, on November 1, 2011. There was no documentation of an individual treatment plan in client record # 4, at the time of the review on February 23, 2011.
The facility director was interviewed on February 23, 2011 and confirmed that individual treatment plans had not been completed for clients # 3 and 4.
|
Plan of Correction
Facility Director will provide training related to completion of an Individual Treatment and Rehabilitation plan. Facility Director will complete random chart audits to ensure that an Individual Plan is completed and on file for each patient after the third individual counseling session or 45 days which ever comes first. Training will be completed by 4/15/2011. |