INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 26 and April 28, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Abstinent Living At The Turning Point At Washington, 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 May 27, 2011.
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Plan of Correction
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records and interview with the Office Supervisor, the facility failed to document physical examinations in two of six client records.The findings include:Six client records were reviewed on April 28, 2011. Physical examinations were required in six client records. The facility failed to document physical examinations per facility policy, within 7 days of admission, in client records # 5 and 6.Client # 5 was admitted into treatment on October 4, 2010 and discharged on November 2, 2010. A physical examination was due to be completed no later than October 11, 2010. There was no documentation of a physical examination in client record # 5.Client # 6 was admitted into treatment on September 21, 2010 and discharged on January 21, 2011. A physical examination was due to be completed no later than September 28, 2010. There was no documentation of a physical examination in client record # 6.The Office Supervisor was interviewed on April 28, 2011 and confirmed that physical examinations were not documented in client records # 5 and 6.
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Plan of Correction
There is a requirement in place for physical examinations of the clients within 7 days of admission.
As of April 28, 2011, the treatment centers we work with were advised of the requirement for physical examinations. Additionally, as of April 28, 2011, our staff members have been re-trained by the Office Supervisor to ensure that the physical examination is obtained within 7 days of admission.
This will be monitored and supervised by the Office Supervisor and the Project Director.
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709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records and staff interviews, the facility failed to document short term goals for treatment as formulated by both staff and client in three of six client records.The findings include:Six client records were reviewed on April 28, 2011. Six client records required long and short term goals for treatment as formulated by both staff and client. The facility failed to document short term goals in client records # 3, 5 and 6.Client # 3 was admitted into treatment on November 12, 2010. The individual treatment plan was completed on November 12, 2010. The treatment plan did not include documentation of short term goals, at the time of the review on April 28, 2011.Client # 5 was admitted into treatment on October 4, 2010 and discharged on November 2, 2010. The individual treatment plan was completed on October 4 , 2010. The treatment plan did not include documentation of short term goals, at the time of the review on April 28, 2011.Client # 6 was admitted into treatment on September 21, 2010 and discharged on January 21, 2011. The individual treatment plan was completed on September 21, 2010. The treatment plan did not include documentation of short term goals, at the time of the review on April 28, 2011.The Project/Facility Director and Office Supervisor were interviewed on April 28, 2011 and both confirmed these treatment plans did not include short term goals.
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Plan of Correction
There is a requirement in place for documentation of short term goals for treatment on the individual treatment plan at the time of admission. On April 28, 2011, our therapists were re-trained by the Office Supervisor to ensure that short term goals for treatment are always included on the individual treatment plan as formulated by the therapist and client.
This will be monitored and supervised by the Office Supervisor and the Project Director.
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