INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 7, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab After Work 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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709.92(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 and the facility's policies and procedures, the facility failed to document a comprehensive treatment plan to include proposed types of supportive services. The findings include:In reference to treatment plans, the project's policy stated: The comprehensive treatment plan shall include, but not be limited to, written documentation of a proposed type of support services. Services may include medical, psychiatric or mental health services, financial, legal, AA, NA, etc.Six client records were reviewed for comprehensive treatment plan that included support services on March 7, 2013. Two out of six client records lacked documentation of a treatment plan that included a proposed type of support service, specifically client records # 4 and 6.Client #4 was admitted on August 16, 2012 and discharged on October 11, 2012. The comprehensive treatment plan was documented on August 16, 2012; however it did not include a proposed type of support service for client #4. Client #6 was admitted on January 2, 2013 and discharged on January 31, 2013. The comprehensive treatment plan was documented on January 20, 2013; however it did not include a proposed type of support service for client #6. The findings were reviewed with the Site Director prior to the exit interview.
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Plan of Correction
The site director will provide in-service training on 4/8/2013 addressing comprehensive treatment planning. This in-service will include the scope of appropriate support services and the required documentation of this in treatment planning. All counselors will participate in this training and will sign off that they understand the requirements regarding comprehensive treatment planning.
The site director will perform random monthly chart audits to ensure that the standard is being met. Chart audits will be ongoing to ensure that the center is in full compliance. |
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 review of client records and the facility ' s policies and procedures, the facility failed to document an aftercare plan in accordance with the project ' s policies and procedures.The findings include:In reference to aftercare plans the project ' s policy states: A Continuing Care Plan is to be completed within one month of the scheduled discharge date ....in relation to ongoing individual sessions. To be completed and signed by the counselor and client prior to discharge. One client record was reviewed for documentation an aftercare plan on March 7, 2013. One out of one client record lacked documentation of an aftercare plan, specifically client record # 4. Client #4 was admitted on August 16, 2012 and discharged on October 11, 2012. As of the date of inspection, there was no aftercare plan documented for client # 4. The findings were confirmed by the Site Director during the exit interview.
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Plan of Correction
The site director will provide in-service training on 4/15/2013 to address the proper utilization of aftercare planning. This in-service will address the requirements for aftercare planning and the need for consistent use of aftercare planning with clients. All counselors will participate in this training and will sign off that they understand the requirements regarding aftercare planning.
The site director will perform random monthly chart audits to ensure that the standard is being met. chart audits will be ongoing to ensure that the center is in full compliance. |