This report is a result of an on-site licensure renewal inspection conducted on April 14, 2008 through April 15, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House, 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 May 12, 2008.
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Plan of Correction
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Observations
Based on a review of the project's policy and procedure manual and client records, the facility failed to document physical examinations according to project policy in three of six records reviewed, #2, 4 and 6. Physical examinations were not completed within the time frame identified in the project's written policy in two records reviewed, #4 and 6. The physical examination was documented ten days late in record #4 and two months late in record #6. A physical examination was missing in one record reviewed, #2.
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Plan of Correction
The policy with respect to physical examinations has been changed as follows:
During the referral and admission process, the Clinical Coordinator will determine if a recent physical examination exists. Whenever possible, a request for the records will be made prior to the client's admission. If upon admission, it is determined that a physical exists, a request for the records will be made. Colonial House will allow for a reasonable period for the receipt of the records. If after three weeks the records are not received an appointment will be scheduled for a physical.
Should it be determined that a recent physical does not exist, the Clinical Coordinator will advise the Executive Assistant and when possible an appointment will be scheduled for a physical within the first week of treatment. This will be subject to the availability of appointments with the physician's office.
The Executive Assistant is responsible for monitoring and ensuring the receipt of all requested medical records. Any issues will be communicated to the Director of Operations. |