INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 3, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Carolyn Mottor-Rivera Counseling 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)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in two out of four client records reviewed.
Client #2 was admitted on September 09, 2022 and was still active at the time of the inspection. A treatment plan was developed on April 04, 2023, this frequency of treatment was noted as " ... one to two individual counseling appointment(s) per week. "
Client #4 was admitted on July 11, 2022 and was discharged on October 10, 2022. A comprehensive treatment plan was developed on July 20, 2022, the frequency of treatment was noted as " ...two to three individual counseling appointments per week. "
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In response to citation 709.92 (a)(2) the director will comply with 709.92 (a)(2) policies and procedures that include an emphasis on each individual treatment and rehabilitation plan shall be developed with each client; and this plan will include written documentation: (2) type and frequency of treatment and rehabilitation services.
Correction of 709.92 (a)(2) was placed into effect on 05/10/2023.
- facility will ensure that each individual treatment and rehabilitation plan will be developed with client.
- the facility will ensure that each treatment and rehabilitation plan developed with each client will include written documentation that includes type and frequency of rehabilitation services on each individual treatment and rehabilitation plan.
- the director will monitor compliance on a weekly basis, or as needed, to review compliance of 709.92 (a)(2) procedures to maintain that all subsequent treatment and rehabilitation plans include written documentation of type and frequency of treatment and rehabilitation services.
-Client #2 treatment plan was updated on 05/18/2023 and is in compliance with 709.92 (a)(2).
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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 document proposed type of support service on individual treatment plans in two out of four records reviewed.
Client #1 was admitted on March 1, 2023 and was still active at the time of the inspection. The comprehensive treatment plans was dated March 3, 2023.
Client #2 was admitted on September 2, 2022 and was still active at the time of the inspection. The comprehensive treatment plans was dated September 16, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In response to citation 709.92 (a)(3) the director will comply with 709.92 (a)(3) policies and procedures that include an emphasis on each individual treatment and rehabilitation plan shall include written documentation of: (3) Proposed type of support services.
-Correction of 709.92 (a)(3) was placed into effect on 05/10/2023.
-facility will ensure that each individual treatment and rehabilitation plan will include written documentation of proposed type of support services.
- the director will monitor compliance on a weekly basis, or as needed, to review compliance of 709.92 (a)(3) procedures to maintain that all subsequent treatment and rehabilitation plans include written documentation of proposed type of support services.
Client #1 treatment plan was updated on 05/10/2023,and is in compliance with 709.92 (a)(3).
Client #2 treatment plan was updated on 05/18/2023,and is in compliance with 709.92 (a)(3).
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