INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 3-4, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Salvation Army Harbor Light 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 and a plan of correction is due on April 3, 2008.
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Plan of Correction
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of the client records on March 4, 2008, the facility failed to document a review of the client's progress in treatment relative to the goals and objectives of the previous treatment plan in two of two client records. Refer to client records # 6 and 7.
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Plan of Correction
Treatment and rehabilitation plans shall be reviewed and updated at least every 60-days.
Outpatient therapist shall review and update the treatment plan at least every 60-days as per compliance standard.
Clinical Supervisor shall randomly review active files each month to insure compliance. |