INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 25-27, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Montgomery County MH/MR Emergency Services, 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 March 31, 2009.
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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
Based on a review of client records, the facility failed to document a treatment plan update in one of one client record.
Findings:
Five client records were reviewed on February 27, 2009. A treatment plan update was required in one client record.
The facility did not document a treatment plan update at least every sixty days in client record # 1.
In client record # 1 the treatment plan updates were documented 03/03/08, 05/07/08, 10/10/08 and 12/15/08.
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Plan of Correction
Treatment and rehabilitation plans will be updated every 60 days. If clients cancel the next visit, besides documenting the reason for the cancellation in a progress note, the treatment plan will be updated in the absence of the client. Will then obtain the client's signature on the treatment plan at the next visit.
The outpatient secretary will be responsible to monitor the charts.
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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
Based on a review of client records, the facility failed to document counseling services provided according to the individual treatment plan in one of one client record.
Findings:
Five client records were reviewed on February 27, 2009. Documentation of counseling services according to an individual treatment plan was required in one client record. The facility did not document counseling services according to the treatment plan in client record # 1.
Record # 1, treatment plan updated on 05/07/08 states individual sessions 1x monthly, but individual session progress notes were documented on 05/07/08, 05/20/08 (session canceled), 05/23/08, 06/23/08 (session canceled) and 10/10/08.
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Plan of Correction
Treatment plans will clearly specify the frequency of the visits. If during the time period the frequency of visits changes, treatment plans will be updated to indicate the revised frequency of visits. Progress notes will reflect the reason for this change. Outpatient therapists and outpatient secretary will be responsible to monitor treatment plans and progress notes.
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