INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 14, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Monroe County Counseling Services, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Eight client records were reviewed on December 14, 2017. The facility failed to document disclosure in 8 client records.
Client # 1 was admitted November 16, 2017 and was still active in treatment.
Client # 2 was admitted November 17, 2017 and was still active in treatment.
Client # 3 was admitted September 14, 2017 and was still active in treatment.
Client # 4 was admitted October 18, 2017 and was still active in treatment.
Client # 5 was Admitted September 30, 2017 and was still active in treatment.
Client # 6 was admitted March 29, 2017 and discharged June 17, 2017.
Client # 7 was admitted April 7, 2017 and discharged June 15, 2017.
Client # 8 was admitted March 28, 2017 and discharged April 30, 2017.
These finding were reviewed with facility staff during the licensing process
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Plan of Correction
An approved Plan of Correction is not on file. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Eight client records were reviewed on December 14, 2017. The facility failed to document client orientation to the project in eight client records.
Client # 1 was admitted November 16, 2017 and was still active in treatment.
Client # 2 was admitted November 17, 2017 and was still active in treatment.
Client # 3 was admitted September 14, 2017 and was still active in treatment.
Client # 4 was admitted October 18, 2017 and was still active in treatment.
Client # 5 was Admitted September 30, 2017 and was still active in treatment.
Client # 6 was admitted March 29, 2017 and discharged June 17, 2017.
Client # 7 was admitted April 7, 2017 and discharged June 15, 2017.
Client # 8 was admitted March 28, 2017 and discharged April 30, 2017.
These finding were reviewed with facility staff during the licensing process
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Plan of Correction
An approved Plan of Correction is not on file. |
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
Eight client records were reviewed on December 14, 2017. The facility failed to document written consent to treatment in eight records.
Client # 1 was admitted November 16, 2017 and was still active in treatment.
Client # 2 was admitted November 17, 2017 and was still active in treatment.
Client # 3 was admitted September 14, 2017 and was still active in treatment.
Client # 4 was admitted October 18, 2017 and was still active in treatment.
Client # 5 was Admitted September 30, 2017 and was still active in treatment.
Client # 6 was admitted March 29, 2017 and discharged June 17, 2017.
Client # 7 was admitted April 7, 2017 and discharged June 15, 2017.
Client # 8 was admitted March 28, 2017 and discharged April 30, 2017.
These finding were reviewed with facility staff during the licensing process
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Plan of Correction
An approved Plan of Correction is not on file. |
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
Eight client records were reviewed on December 14, 2017. The facility failed to document an individual treatment and rehabilitation plan in seven of eight client records.
Client # 1 was admitted November 16, 2017 and was still active in treatment.
Client # 2 was admitted November 17, 2017 and was still active in treatment.
Client # 3 was admitted September 14, 2017 and was still active in treatment.
Client # 4 was admitted October 18, 2017 and was still active in treatment.
Client # 5 was Admitted September 30, 2017 and was still active in treatment.
Client # 7 was admitted April 7, 2017 and discharged June 15, 2017.
Client # 8 was admitted March 28, 2017 and discharged April 30, 2017.
These finding were reviewed with facility staff during the licensing process
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Plan of Correction
An approved Plan of Correction is not on file. |
709.93(a) LICENSURE Client records
709.93. 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:
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Observations
Based on a review of eight client records, the facility failed to document progress notes in 6 clients records. Additionally, the facility failed to document records of services in 8 records reviewed.
Client # 1 was admitted November 16, 2017 and was still active in treatment. Client record was missing progress notes and record of services.
Client # 2 was admitted November 17, 2017 and was still active in treatment. Client record was missing progress notes and record of services.
Client # 3 was admitted September 14, 2017 and was still active in treatment. Client record was missing progress notes and record of services.
Client # 4 was admitted October 18, 2017 and was still active in treatment. Client record was missing progress notes and record of services.
Client # 5 was Admitted September 30, 2017 and was still active in treatment. Client record was missing progress notes and record of services.
Client # 6 was admitted March 29, 2017 and discharged June 17, 2017. Client record was missing record of services.
Client # 7 was admitted April 7, 2017 and discharged June 15, 2017. Client record was missing record of services.
Client # 8 was admitted March 28, 2017 and discharged April 30, 2017. Client record was missing progress note and record of services.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |