INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on June 13, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Asociacion De Puertorriquenos En Marcha 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 July 14, 2008.
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Plan of Correction
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709.92(a) 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:
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Observations
Based on a review of seven client records, four were required to have comprehensive treatment plans. The facility failed to document the accurate date for the completion of the comprehensive treatment plan in one of four records reviewed, #3. The comprehensive treatment plan was signed and dated by the counselor as completed on June 19, 2008 even though the date of the complaint investigation was on June 13, 2008.
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Plan of Correction
Program supervisor will review all clinical charts on the monthly basis using a template tracking sheet. This tracking sheet will identify the targeted deadline for all clinical documentation. Counselor will submit document for review to supervisor. Program supervisor will check for accuracy of dates and clinical content. If incorrect program supervisor will return form back to counselor for revision. Once correction is made, supervsisor will authorize the filing of form in patient's chart. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of seven client records, one was required to have two case consultations. The facility failed to document the second of two case consultations in one of one record reviewed, #5. The client was in treatment from October 2007 to April 2008. One case consultation was documented on 12/11/07 and there were no other case consultations documented in the record. A case consultation was due 3/11/08.
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Plan of Correction
Vp of health instructed program supervisor to create a supervision time slot on the weekly basis with clinicians to discuss charts. Program supervsior was also advice to create a tickler system flow chart which alerts the clinicians when clinical documentation needs to be be updated. Charts reviewed will be updated by counselor to reflect new case consultations and/or any other clinical documentation. This process will be follow up on the monthly basis by program supervisor. |