INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 6-7, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Organization for Women in Early Recovery 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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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in two of four client records.
The findings included:
Four client records were reviewed on December 7, 2011. Each of the records was required to have a psychosocial evaluation documented. The facility policy and procedure manual states a psychosocial evaluation is to be completed within 30 days of admission. Two of the four client records did not include documentation of a psychosocial evaluation.
Client record # 3 - The client was admitted August 11, 2011. A psychosocial evaluation was due by September 11, 2011. A psychosocial evaluation was not documented as of December 7, 2011.
Client record # 4 - The client was admitted October 11, 2011. A psychosocial evaluation was due by November 11, 2011. A psychosocial evaluation was not documented as of December 7, 2011.
This was discussed with and confirmed by the clinical supervisor on December 7, 2011.
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Plan of Correction
The Halfway House Program Manager will inspect clinical records on a regular basis to make certain that the psychosocial evaluation is documented within 30 days of admission and according to POWER's policy and procedure manual. The Program Manager will provide education, supervision and oversight to clinical staff regarding documentation of the psychosocial evaluation. POWER is expected to be in full compliance by 1/27/2012. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of four client records.
The findings included:
Four client records were reviewed on December 7, 2011. The type and frequency of services was required in the individual treatment and rehabilitation plan in four client records.
Three of the four client records did not include documentation of the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
Client record #2 - The client was admitted June 16, 2011, and was discharged on October 14, 2011. An individual treatment and rehabilitation plan was completed on 7-14-2011, but did not included documentation of the frequency of group therapy.
Client record #3 - The client was admitted August 11, 2011. An individual treatment and rehabilitation plan was completed on 9-12-2011 and on 10-18-11, but neither plan included documentation of the frequency of individual or group therapy.
Client record #4 - The client was admitted October 11, 2011. An individual treatment and rehabilitation plan was completed on 11-3-2011 and on 11-19-11. Neither plan include documentation of the frequency of group therapy. Neither plan included documentation of individual therapy or the frequency.
This was discussed and confirmed by the clinical supervisor on 12-7-2011.
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Plan of Correction
The Halfway House Program Manager will inspect clinical records on a regular basis to make certain that the type and frequency of treatment and rehabilitation services are properly documented on the individual treatment plan. The Halfway House Manager will provide oversight, supervision and education to clinical staff about documenting type and frequency of rehabilitation services, specifically individual and group therapy, on the individual treatment plans. POWER will be in full compliance by 1/27/2012. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on the review of client records, the facility failed to provide counseling according the facility policy in three of four client records.
The findings included:
Four client records were reviewed on December 7, 2011. The client handbook and facility policy states that clients will receive individual treatment sessions two times per month. Three of the four client records reviewed did not include documentation that the facility provided individual counseling two times per month.
Client record #2 - The client was admitted June 16, 2011, and was discharged on October 14, 2011. The facility did not document individual treatment sessions for August 2011, September 2011, or October 2011.
Client record #3 - The client was admitted August 11, 2011. The facility did not document two individual sessions per month for September 2011 or November 2011.
Client record #4 - The client was admitted October 11, 2011. The facility did not document two individual sessions per month for November 2011.
This was discussed with and confirmed by the clinical supervisor on 12-7-2011.
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Plan of Correction
The Halfway House Program Manager will inspect the clinical records on a regular basis to make sure that individual treatment sessions are being provided at least two times per month per POWER's policy. The Halfway House Program Manager will provide education, oversight and supervision to clinical staff about providing and documenting individual treatment sessions two times per month or more frequently if indicated on the individual treatment plan. POWER is expected to be in full compliance by 1/27/2012. |
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 the review of the client records, the facility failed to document individual counseling sessions on the record of service in three of four client records.
The findings include:
Four client records were reviewed on December 7, 2011. The record of service documentation was required in four client records. The facility did not document the individual counseling sessions on the record of service in client records #2, #3 and #4.
Client record #2 - The client was admitted June 16, 2011, and was discharged on October 14, 2011. The record of service did not include documentation of the individual counseling sessions provided to the client. Progress notes documented that individual counseling sessions occurred, but there were no entries of this service on the record of service.
Client record #3 - The client was admitted August 11, 2011. The record of service did not include documentation of an individual counseling session provided to the client. Progress notes documented that an individual counseling session occurred, but there is no entry of this service on the record of service.
Client record #4 - The client was admitted October 11, 2011. The record of service did not include documentation of the individual counseling sessions provided to the client. Progress notes documented that individual counseling sessions occurred, but there are no entries of this service on the record of service.
This was discussed with and confirmed by the clinical supervisor on 12-7-2011.
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Plan of Correction
The Halfway House Program Manager will inspect the clinical record and record of service on a regular basis to make certain that individual counseling sessions are documented on the record of service. The Halfway House Program Manager will provide education, supervision and oversight to clinical staff to ensure they understand to document individual counseling sessions on the record of service. POWER is expected to be in full compliance by 1/27/2012. |