INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 8 through 10, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program 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 October 20, 2008.
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Plan of Correction
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711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) 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 13 client records on September 9 through 10, 2008, six client records were required to contain proposed support services in the individual treatment and rehabilitation plan. The facility failed to document proposed support services in four of six client records where required.
Findings:
In client records #2, 5 and 6 the documented proposed support services were identical and did not include the specific support services identified in the histories and psychosocial evaluations as required by the project's polices and procedures for proposed support services in the individual treatment and rehabilitation plan. The identical support service identified was attendance at methadone anonymous support groups.
In client record #3 no proposed support services were documented in the individual treatment and rehabilitation plan.
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Plan of Correction
The facility director shall ensure that compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the facility director combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plans will occur in individual supervisory sessions conducted by the facility director. Particular focus shall be placed upon including the patient's participation appropriate support services, including 12-step fellowships among other activities as part of the plan of recovery.
Program leadership will develop a resource manual that contains community resources and will be geared specifically to the issues experienced by individuals participating in the program. The manual will be available for staff use by 11/1/08. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the facility director beginning no later that 11/15/08 and continuing through the course of the licensing review period.
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of 13 client records on September 9 through 10, 2008, six were required to contain a treatment plan update at least every 60 days. The facility failed to provide for a complete review and update of an individual treatment and rehabilitation plan in four of six client records where required.
Findings:
In client records #1, 2, 8 and 9 the treatment plan updates stated the goals were unresolved. There was no assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan. In addition in client record #3, new goals were added and unresolved goals were dropped from the comprehensive treatment plan with no documented explanation as required by the project's polices and procedures for treatment plan updates.
In client record #7 there was no documentation of the client's progress in relationship to the stated goals of the comprehensive treatment plan on all the treatment plan updates. In addition, all the treatment plan updates restated and re-dated the goals established in the comprehensive treatment plan with no review and update documented.
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Plan of Correction
The facility director shall ensure that compliance to developing individualized treatment plan updates in timely fashion will be evidenced by periodic quality reviews by the facility director combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plan updates will occur in individual supervisory sessions conducted by the facility director. The necessity of inclusion of this information will be conveyed to staff in individual supervisory sessions conducted by the facility director beginning no later than 11/15/08 and continuing through the course of the licensing review period. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of 13 client records on September 9 through 10, 2008, three client records were required to contain an aftercare plan. The facility failed to document an aftercare plan in two of three client records reviewed.
Findings:
In client records #10 and 13 the aftercare plan was not documented. Aftercare plans are developed for all individuals upon intake and completed for all individuals who complete treatment as required by the project's policies and procedures for aftercare plans. Aftercare plans for client records #10 and 13 were not documented.
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Plan of Correction
The facility director shall ensure that compliance will be evidenced by reviews of all files pending discharge for thoroughly completed Aftercare Plans when applicable during individual supervision by the facility director. Reentry guidelines and contact procedures will be documented consistently when an Aftercare Plan is completed. Staff training about completion of Aftercare Plans will be provided by the facility director. This will be conveyed to staff by the Facility Director; at a staff meeting held by 11/15/08. The reviews and supervision will begin immediately. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of 13 client records on September 9 through 10, 2008, six client records were required to contain follow-up information. The facility failed to document follow-up information in four of six client records reviewed.
Findings:
In client records #5, 7, 8, and 12 the follow-up information was not documented.
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Plan of Correction
The facility director shall ensure that each clinician pursues the act of follow-up contacts on each patient who is discharged from services. Staff training about completion of followup will be provided by the facility director. This will be conveyed to staff by the Facility Director at a staff meeting held by 11/15/08. The reviews and supervision will begin immediately. |