INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 27-29,2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clearfield Jefferson Community Mental health Center, 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 August 24, 2010.
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Plan of Correction
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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to document type and frequency of services to be offered to each client on each treatment plan as required.
The findings included:
Six client records were reviewed during the inspection.. Each was required to include documentation of of the type and frequency of treatment to be given each client on the treatment plan. This issue was also cited at the 2009 inspection. Two of six records reviewed failed to include treatment plans with documentation of the type and frequency of treatment.
Record # 2 - admitted on 2/25/10 - failed to document type and frequency of services to be offered on the individual treatment plan formulated on 3/30/10.
Record # 6 - admitted 6/2/10 - failed to document the type and frequency of service to be offered on the treatment plan formulated on 6/29/10.
An ongoing dialogue was held with the clinical supervisor throughout the inspection and the findings were reviewed on an ongoing basis with her. She did not dispute the veracity of the findings.
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Plan of Correction
During a staff meeting on 8/3/10, the therapists were re-trained on treatment plan formulation, specifically type and frequency of treatment rehabilitation services. The supervisor provided a copy of a sample treatment plan for referencing purposes. As on ongoing practice, treatment plans that do not clearly indicate type and frequency during chart audits and prior to signature will be returned to clinician for correction. Random chart audits by the supervisor as well as peer reviewed audits will continue to occur monthly. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of the client records, the facility failed to document support services to be offered to each client on each treatment plan as required.
The findings included:
Six client records were reviewed during the inspection.. Each was required to include documentation of of support services for the client on the treatment plan. This issue was also cited at the 2009 inspection. Two of six records reviewed failed to include documentation of support service on the treatment plan.
Record # 1 - admitted on 4/7/10 - failed to include documentation of support services on the individual treatment plan formulated on 5/6/10.
Record # 5 - admitted 10/9/09 - failed to include documentation of support services on the individual treatment plan formulated on 11/10/09.
An ongoing dialogue was held with the clinical supervisor throughout the inspection and the findings were reviewed on an ongoing basis with her. She did not dispute the veracity of the findings.
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Plan of Correction
During a staff meeting on 8/3/10, the therapists were re-trained on treatment plan formulation, specifically reviewing support services inclusion. The treatment plan document was also amended for the clinician to list the support services available to the client. The supervisor provided a copy of a sample treatment plan for referencing purposes. As on ongoing practice, treatment plans that do not clearly indicate support services during chart audits and prior to signature will be returned to clinician for correction. Random chart audits by the supervisor, as well as, peer-reviewed audits will continue to occur monthly. |