INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Laure Rohrs Gargano was found not to be in compliance with the application chapters of 28 PA Code which 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(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
The facility failed to update treatment plans at least every sixty days in 2 out of 5 client records, based on a review of client records on July 9, 2018.
Client #1 was admitted on January 18, 2018 and was still active at the time of the inspection. An initial comprehensive treatment plan was completed on February 1, 2018 and the next update was due no later than April 1, 2018; however, it was not updated until April 26, 2018. The following treatment plan update was due no later than June 26, 2018; however, there was no update documented in the client record at the time of inspection.
Client #2 was admitted on February 17, 2017 and was still active at the time of the inspection. The client had had a treatment plan update completed on January 9, 2018 and the next was due no later than March 9, 2018; however, it was not updated until March 19, 2018. The following treatment plan update was completed on May 8, 2018 and the next update was due no later than July 8, 2018; however, there was no update documented in the client record at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The assigned counselor will utilize EMR reminders for required chart entries that are due. When/If unable to complete on time, the counselor will make a notation in the record reflecting why an update was not completed within timeframe; the assigned counselor will alert the Program Director and document in the EMR the next available target to date to complete the required update. The Program Director will monitor compliance and track occurrences.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to assure that counseling services were provided according to the individual treatment plan in 2 out of 5 client records that were reviewed on July 9, 2018 during an onsite inspection.
Client #1 was admitted on January 18, 2018 and was still active at the time of the inspection. The comprehensive individual treatment plan dated February 1, 2018, indicated individual counseling weekly. The client's record of service and progress notes indicated that the client did not receive individual counseling for the weeks of : March 8, 2018, April 22, 2018, May 20, 2018, May 27, 2018 and June 24, 2018.
Client #3 was admitted on March 16, 2018 and was still active at the time of the inspection. The comprehensive individual treatment plan dated March 30, 2018, indicated individual counseling weekly. The client's record of service and progress notes indicated that the client did nto receive individual counseling for the weeks of : May 2, 2018 and May 21, 2018.
Client #7 was admitted on March 19, 2018 and was still active at the time of the inspection. The comprehensive individual treatment plan dated March 29, 2018, indicated individual counseling weekly. The client's record of service and progress notes indicated that the client did not receive individual counseling for the weeks of : April 23, 2018, April 30, 2018, May 14, 2018 May 28, 2018, June 11, 2018, June 18, 2018, June 25, 2018 and July 2, 2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
When the frequency of sessions, level of care, type of service provided changes; the assigned counselor will make a chart entry reflecting the rationale for the change in services. At the time of a change in services the assigned counselor will update the treatment plan with the client reflecting the change in service. The Program Director will review the changes and countersign the treatment plan update.
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