INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16-17, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Persad Center, 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 October 12, 2009.
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Plan of Correction
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to provide written documentation of proposed support services in the individual treatment and rehabilitation plans, in three of four client records.The findings include:Eight outpatient client records were reviewed on September 17, 2009. The individual treatment and rehabilitation plans were required to document proposed support services in four client records. The facility did not document proposed support services in client records # 1, 2 and 4.
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Plan of Correction
The Program Director will revise the existing drug & alcohol treatment plan to include 'support services' by October 31, 2009. The Program Director will review the standards for treatment planning and the new treatment plan form with all clinical staff in Group Supervision on November 2, 2009. The new treatment plan form will be implemented on November 3, 2009. All treatment plans for clients receiving treatment in Persad's Drug & Alcohol Program will include a goal for support services by December 1, 2009. The Quality Assurance team will complete a focused chart audit to ensure compliance in March 2010. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of service which included a chronological listing of all services provided to the client in four of four client records.The findings include:Eight outpatient client records were reviewed on September 17, 2009. A record of service including all services provided to the client were required in four client records. The facility did not document a complete record of service in client records #1, 2, 3 and 4.
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Plan of Correction
The Program Director will develop procedures and a new form for tracking record of services that meets the criteria described in 709.93 by October 31, 2009. The Program Director will review new procedures with all clinical staff in Group Supervision on November 2, 2009. The new Record of Services form and procedures will be implemented on November 3, 2009. All current clinical records will have updated Record of Services forms by November 30, 2009. The Quality Assurance team will complete a focused chart audit to ensure compliance in March 2010. |