INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 13, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site investigation, Another Way, 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 April 10, 2009.
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Plan of Correction
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on client record reviews, the facility failed to provide counseling services as stated on the treatment plan in one of three client records.
The findings include:
Three client records were reviewed on March 13, 2009. Counseling services are required to be provided according to the treatment plan in three client records. The facility did not document counseling services provided according to the treatment plan in client record # 2. The client's treatment plan states that individual sessions will occur once per week. It is documented that the client had an individual session on December 31, 2008 and did not receive another individual session until January 23, 2009.
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Plan of Correction
The course of action for observation 1773 is that a clinical staff meeting will be held on 4/2/09. During this meeting the importance of weekly individual sessions and proper documentation will be addressed by the Facility Director to all therapists. To maintain compliance of this standard the Facility Director will ensure that monthly chart audits are being completed by the Administrative Assistant. The Facility will be in full compliance on 4/2/09. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on client record reviews, the facility failed to document a record of service which included the date and type of service provided to the client in three of three client records.
The findings include:
Three client records were reviewed on March 13, 2009. A record of service including the date and type of service was required in three client records. The facility failed to document the date and type of service provided in client records # 1, 2 and 3.
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Plan of Correction
The course of action for observation #1797 is that the Facility Director will train staff to properly document activities on the facility's activity log. This staff meeting will take place on 4/2/09. The Facility Director will ensure that the Administrative Assistant is completing monthly chart audits to maintain compliance. This standard will be met on 4/2/09. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on client record reviews, the facility failed to document an aftercare plan in one of three client records.
The findings include:
Three client records were reviewed on March 13, 2009. Aftercare plans were required in three client records. The facility did not document an aftercare plan in client record # 2.
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Plan of Correction
The facility was in non-compliance due to client #2 not handing in the continuing care agreement. The course of action for observation 1809 is that a clinical staff meeting will be held on 4/2/09. During this meeting the importance of discharge planning and obtaining proper discharge paperwork will be addressed by the Facility Director. To maintain compliance of this standard the Facility Director will ensure that quality assurance is completed by the Administrative Assistant, who will complete monthly chart audits on the discharged client's charts. The Facility will be in full compliance on 4/13/09. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on client record reviews, the facility failed to document a discharge summary in one of three client records.
The findings include:
Three client records were reviewed on March 13, 2009. A discharge summary was required in three client records. The facility did not document a discharge summary in client record # 2.
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Plan of Correction
The facility was in non-compliance due to chart #2 not having a discharge summary completed. The course of action for observation 1811 is that a clinical staff meeting will be held on 4/2/09. During this meeting the importance of discharge planning, documenting on the discharge summary and a time frame in which paperwork must be completed will be addressed by the Facility Director. To maintain compliance of this standard the Facility Director will ensure that quality assurance is completed by the Administrative Assistant, who will complete monthly chart audits on the discharged client's charts. The Facility will be in full compliance on 4/13/09. |