INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 5, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Outside In Pathway to Recovery Outpatient Services 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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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a signed consent to treatment in one of five client records.
The findings include:
Five client records were reviewed on February 5, 2014. All five client records were required to include a signed consent to treatment form. The facility failed to document a signed consent to treatment form in client record # 2.
Client #2 was admitted to treatment on August 19, 2013 and discharged on September 25, 2013. The consent to treatment form contained in client record # 2 was not signed by the client.
The findings were confirmed with the clinical supervisor and facility director.
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Plan of Correction
The clinical director will review policy on clinical documentation with clinical supervisor's and counselors. Clinical supervisor will monitor all treatment record to verify that all records have signed consent to treatment for every client in treatment. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a signed preliminary treatment and rehabilitation plan in one of five client records.
The findings include:
Five client records were reviewed on February 5, 2014. All five client records required the documentation of a signed preliminary treatment and rehabilitation plan. The facility failed to document a signed preliminary treatment and rehabilitation plan in client record # 2.
Client #2 was admitted on August 19, 2013 and discharged on September 25, 2013. A preliminary treatment and rehabilitation plan included in the record was dated August 28, 2013. However, the facility failed to have the client sign the preliminary treatment and rehabilitation plan and there was no evidence in the record to indicate that the client was made aware of the information contained on the preliminary treatment plan.
The findings were reviewed with the facility director and clinical supervisor.
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Plan of Correction
The clinical director will review policy on clinical documentation with clinical supervisor's and counselors. Clinical supervisor will monitor all treatment record to verify that all records have a completed preliminary treatment plan and signed for every client in treatment. |