INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 8, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Oil Region Recovery, 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:
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Plan of Correction
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultation notes in three of seven client records.
The facility policy and procedure states, case consults must be conducted within the first 15 days and every 30 days thereafter for residential clients.
Client #11 was admitted to the residential level of care on February 22, 2023 and was active at the time of review. A case consultation note was to be documented in the client record on or before March 9, 2023. A case consultation note was not documented until March 22, 2023.
Client #12 was admitted to the residential level or care on October 19, 2022 and was discharged November 16, 2022. A case consultation note was to be documented in the client record on or before November 3, 2022. No case consultation note was documented in the client record.
Client #14 was admitted to the residential level of care on March 7, 2023 and was active at the time of review. A case consultation note was to be documented in the client record on or before March 22, 2023. No case consultation note was documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each counselor will have case consult reviews on a weekly basis during the morning staff meeting to prevent case consults from getting missed. Clinical Director will monitor each counselors' caseload for timing of the case consults to meet the 15-day standard. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of four client records.
Client #9 was admitted to the residential level of care on September 1, 2022 and was discharged January 31, 2023. Follow-up information was to be obtained on February 7, 2023. No follow-up information was documented in the client record.
Client #10 was admitted to the residential level of care on November 7, 2022 and was discharged January 27, 2023. Follow-up information was to be obtained on February 3, 2023. No follow-up information was documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up call sheet was moved to a different location in the chart with the aftercare documents so counselors will fill out at the time of doing the aftercare documents. The paper had been filed in a part of the chart that counselors don't access after admission, and it was being missed. This will be followed by the Clinical Director and updated with Admin Assistant weekly. |