INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 15, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Adappt Outpatient Services 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 February 13, 2009.
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Plan of Correction
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative documentation, the facility failed to document a written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
Findings:
Administrative Documentation was reviewed on January 15, 2009. A written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage was required. The facility failed to document a written agreement for 24-hour emergency psychiatric and medical coverage.
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Plan of Correction
The Director of Administrative Services has obtained current documentation of a written agreement with the Reading Hospital & Medical Center for 24-hour emergencey psychiatric and medical coverage. A copy of this agreement has been placed in the Outpatient Manual. The Director of Administrative Services will ensure that this agreement will be reviewed and updated at least every two years. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on a review of administrative documentation, the facility failed to demonstrate a data collection and record keeping system that allows for the efficient retrieval of information.
The findings include:
Administrative documentation was reviewed on January 15, 2009. The facility was required to demonstrate the retrieval of needed data efficiently. The facility was unable to provide a list of active/discharged clients with admission dates and discharge dates.
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Plan of Correction
The Facility Director has developed a data collection and record-keeping system that will allow for the efficient retrieval of data needed to measure the project's performance in relationship to ADAPPT'S goals and objectives. Training has been provided to the Outpatient Counselor on the appropriate use of this system. The Facility Director will ensure that a list of active/discharged clients with admission dates and discharge dates is available at all times.
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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 a review of client records, the facility failed to document treatment plan updates every thirty days, as stated in their policy and procedures manual, in three of four client records.
The findings include:
Six client records were reviewed on January 16, 2009. Treatment plan updates were required in four client records. The facility failed to document treatment plan updates at least every thirty days in client records # 1, 2 and 4.
Client record # 1, comprehensive treatment plan completed 12/09/08; treatment plan update not completed at time of inspection.
Client record # 2, comprehensive treatment plan completed 12/03/08; treatment plan update not completed at time of inspection.
Client record # 4, comprehensive treatment plan completed 11/20/08; treatment plan update not completed at time of inspection.
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Plan of Correction
The Facility Director will immediatley begin to meet with the Outpatient Counselor at least every thirty days for client chart review. During these reviews the Facility Director will ensure that the Counselor has documented the required treatment plan updates at least every 30 days as stated in the ADAPPT Policy and Procedure Manual. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultation notes at least once during treatment, as stated in their policy and procedures manual, in two of two client records.
The findings include:
Six client records were reviewed on January 16, 2009. Case consultation notes were required in two client records. The facility failed to document case consultation notes in client records # 5 and 6.
Client record # 5, admission date 08/05/08, discharge date 11/05/08, case consultation note not documented.
Client record # 6, admission date 06/10/08, discharge date 10/08/08, case consultation note not documented.
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Plan of Correction
The Outpatient Counselor will ensure that Case Consultation notes are documented and placed in the client's file at least every 30 days. The Facility Director will monitor this procedure during client chart reviews to ensure compliance.
The ADAPPT Outpatient Policy and Procedure Manual has been revised as of February 2, 2009 to reflect the timeframe change from at least once during treatment to every 30 days. |