INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensure inspection that was conducted on August 27, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the supervisory review of findings from the on-site inspection, Conewago Place, 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 supervisory review:
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Plan of Correction
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on review of client records, the facility failed to provide a complete client record, which is to include verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
Client #1 admitted on June 21, 2019 was still an active client at the time of the inspection. There was no documentation in the client record verifying that work chores done throughout the entire facility by the client at the project was an integral part of his treatment and rehabilitation plan.
Client #4 admitted on July 29, 2019 was still an active client at the time of the inspection. There was no documentation in the client record verifying that work chores done throughout the entire facility by the client at the project was an integral part of his treatment and rehabilitation plan.
Client #5 admitted on May 24, 2019 was still an active client at the time of the inspection. There was no documentation in the client record verifying that work chores done throughout the entire facility by the client at the project was an integral part of his treatment and rehabilitation plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All the client treatment plans have been corrected to include work therapy as one of the goals. The clinical team was retrained on this expectation on 9/23/19, to ensure these records are complete. The clinical director will review the treatment plans prior to signing off on them to ensure this important component is included. |