INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 15, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ridgeview Adolescent Behavioral Health Center at Pittsburgh 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:
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Plan of Correction
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to document that treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of four client records.
The findings include:
Fourteen client records were reviewed on September 15, 2014. Five client records were reviewed as outpatient records. Four client records required documentation of a treatment and rehabilitation plan update. There was no documentation of treatment and rehabilitation plan updates in client records # 10, 12 and 14.
Client # 10 was admitted on January 30, 2014. The comprehensive treatment plan was completed on February 2, 2014. Treatment plan updates, due by April 2 and June 2, 2014 were not documented.
Client # 12 was admitted on January 23, 2014 and discharged on June 20, 2014. The comprehensive treatment plan was completed on February 3, 2014. A treatment plan update, due by April 3, 2014 was not documented.
Client # 14 was admitted on December 16, 2013 and discharged on June 19, 2014. The comprehensive treatment plan was completed on December 30, 2013. Treatment plan updates, due by March 2 and May 2, 2014 were not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning immediately, all outpatient and intensive outpatient clients will receive and review a documented treatment update every 60 days. Lead Counselor, along with medical records staff will monitor compliance through bi- weekly chart audits. Weekly supervision will be conducted with Outpatient Therapist, by Lead Counselor or Clinical Supervisor, to ensure work is being completed and deadlines are being met. 100% compliance will be achieved by January 1, 2015. |
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 the review of client records, the facility failed to document a complete client record that included case consultation notes and/or an aftercare plan in three of four client records.
The findings include:
Fourteen client records were reviewed on September 15, 2014. Five client records were reviewed as outpatient records. Four client records required documentation of case consultation notes and two client records required documentation of an aftercare plan. Case consultation notes were not documented in client records # 12 and 14. An aftercare plan was not documented in client record #13
Client # 12 was admitted on January 23, 2014. There were no case consultation notes documented as of September 15, 2014.
Client # 14 was admitted on December 16, 2013. There were no case consultation notes documented as of September 15, 2014.
Client # 13 was admitted on May 19, 2014 and successfully discharged on August 7, 2014. There was no aftercare plan documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
a. Beginning immediately, all outpatient and intensive outpatient clients will receive and review Case Consults every 90 days. Lead Counselor, along with medical records staff will monitor compliance through bi- weekly chart audits. Weekly supervision will be conducted with Outpatient Therapist, by Lead Counselor or Clinical Supervisor, to ensure work is being completed and deadlines are being met. 100% compliance will be achieved by January 1, 2015.
b. Beginning immediately, all outpatient and intensive outpatient clients will review with Counselor an aftercare plan, that will be documented in the chart. Weekly supervision will be conducted with Outpatient Therapist, by Lead Counselor or Clinical Supervisor, to ensure work is being completed and deadlines are being met. 100% compliance will be achieved by January 1, 2015.
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