INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clear Concepts Counseling 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 May 19, 2008.
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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 April 16, 2008 review of client records, the facility failed to document an aftercare plan in one of three records reviewed, #5. An aftercare plan was missing.
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Plan of Correction
Our facility will be in full compliance with this standard by 5/16/08. This standard and our agency policy relative to this standard will be reviewed with all counselors at our next staff meeting on 4/29/08. The proper completion and timing of completion of aftercare plans will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a April 16, 2008 review of client records, the facility failed to document follow up information in one of two records reviewed, #6.
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Plan of Correction
Our facility will be in full compliance with this standard by 5/16/08. A review of the necessity for gathering follow up information as well as the appropriate timetable for such will be conducted at our next staff meeting on 4/29/08. The proper documentation of such will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. |