INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, PA Treatment and Healing 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Seven client records were reviewed on September 20, 2017. The facility failed to document an applicable consent to release information for client record # 2.
Client # 2 was admitted into treatment on 7/28/17 and was still active in treatment. Documentation in the client's record indicated that urinalysis specimens were sent to a laboratory on 7/28/17, 8/3/17, 8/18/17, and 8/28/17. A consent to release information to this laboratory was not documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The counselor failed to document a consent to release information to the lab. The counselor will obtain a release of information for the lab during a client's intake session for every client in need of lab services. The Facility Director will ensure compliance with this regulation through supervision, training and quality assurance reviews. This regulation is in compliance effective 10-1-2017. |
709.92(a) 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:
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Observations
Seven client records were reviewed on September 20, 2017. The facility failed to document the frequency of treatment services on the individual treatment and rehabilitation plan for client records # 1, 5, and 6.
Client # 1 was admitted into treatment on 8/18/17 and was still active in treatment. The client's individual treatment and rehabilitation plan, completed on 9/15/17, did not specify the frequency of individual counseling therapy.
Client # 5 was admitted into treatment on 2/1/17 and was discharged on 7/7/17. The client's individual treatment and rehabilitation plan, completed on 2/13/17, did not specify the frequency of individual counseling therapy.
Client # 6 was admitted into treatment on 1/3/17 and was discharged on 4/7/17. The client's individual treatment and rehabilitation plan, completed on 1/17/17, did not specify the frequency of individual counseling therapy.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The counselor failed to document the frequency of individual therapy. The counselor will ensure the frequency of treatment is circled on each treatment plan upon completion. The Facility Director will ensure compliance with this regulation through supervision, review of the manual and regulations training and quality assurance reviews. This regulation is in compliance effective 10/1/2017. |