INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, The Empowerment Resurrection Center 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) 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:
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Observations
Based on a review of 4 client records, the facility failed to provide a complete client record, which is to include aftercare plans and follow up information in 2 client records.
Client #3 was admitted on 2/22/18 and was discharged on 4/20/18. The client record did not contain documentation of an aftercare plan information as of the date of the inspection.
Client #4 was admitted on 1/11/17 and was discharged on 5/25/17. The client record did not contain documentation of follow up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients entering our facility will receive a fully completed After Care Plan, after completion of the treatment. We have the Aftercare Plan developed and it is already in our charts.
Our Project Director will ensure that all future client charts will have a completed Aftercare Plan documented in each chart. He will also ensure that this document is signed by both the counselor and the client.
Our Project Director will also include a follow-up phone call to the client to ensure that the client has attempted to follow the after plan. |