INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 8, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab Management, Inc. 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:
The project ' s policy titled Treatment Management; 60,029; Section C. Comprehensive Treatment Plan (709.92.a), Effective 1/10/11 states:
The Comprehensive Treatment Plan is an individual treatment and rehabilitation plan developed in collaboration with each patient and their assigned Primary Counselor. Four client records were reviewed for comprehensive treatment plan that included support services on March 8, 2013. One out of four client records lacked documentation of a treatment plan that included a proposed type of support service, specifically client record # 1.
Client #1 was admitted on November 10, 2012 and discharged on January 19, 2013. The comprehensive treatment plan was documented on November 11, 2012; however it did not include a proposed type of support service for client #1
The findings were reviewed with the Site Director during the exit interview.
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Plan of Correction
An inservice will be held during the staff meeting on 4-2-13 to review the requirements of incuding support services in treatment planning. This will be documented in the supervision log. Site Director will review charts during quarterly QCI reviews to ensure compliance, as well as reviewing cases during all case consultations for clients. |
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 client records and the facility's policies and procedures, the facility failed to document a treatment plan update where required.
The findings include:
The project ' s policy titled Treatment Management; 60,029; Section D. Treatment Plan Review and Update (709.92.b), Effective 1/10/11 states:
The Comprehensive Treatment Plan shall be reviewed and updated at least every 60 days.
Two client records were reviewed for treatment plan updates on March 8, 2013. One out of two client records lacked documentation of a treatment plan update, specifically client record #1.
Client #1 was admitted to treatment on November 10, 2012 and was still active at the time of inspection. The treatment plan was completed on November 11, 2012. A treatment plan update was due by January 11, 2013. As of the date of inspection, there was no documentation of a treatment plan update for client #1.
The findings were discussed with the Site Director during the time of inspection.
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Plan of Correction
The client in question was discharged due to lack of attendance since 1-19-13, and therefore, a treatment plan update could not be completed with the client. To avoid future concerns, all staff will review the reaqirements of treatment plan updates via an inservice during staff meeting on April 23, 2013. This will be documented in the staff supervision log. All treatment plan updates will be reviewed during subsequent case consultations, and also by Site Director during quarterly QCI audits. |