INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
Part 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
Part 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 24, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Carbon Monroe Pike Drug and Alcohol Commission 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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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven client records the facility failed to ensure individual treatment and rehabilitation plans included written documentation of type and frequency of treatment and rehabilitation services in two records reviewed.
Client # 2 was admitted on February 27, 2020 and discharged on September 16, 2020. A treatment and rehabilitation plan dated April 27, 2020 did not include written documentation of type and frequency of treatment and rehabilitation services.
Client # 5 was admitted March 5, 2020 and was current at the time of the inspection. Treatment and rehabilitation plans dated May 7, 2020, July 9, 2020, September 10, 2020, November 12, 2020, January 14, 2021 and February 4, 2021 did not include written documentation of type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New treatment plans/ Treatment updates were changed and will be on one form to make sure type/ frequency is included on all treatment plan/ updates. This was implemented by the Facility Director. Reviewed with staff and implemented on 3/24/21. Outpatient Treatment Supervisor will review charts weekly to ensure that staff complete treatment plans/ updates with type and frequency of services. |