INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Rehab Management, 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:
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Plan of Correction
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of 7 client records, the facility failed to document follow-up information in 3 complete client records reviewed.
Client #4 was admitted on 11/30/17 and was discharged on 2/21/18.
Client #5 was admitted on 11/4/16 and was discharged on 4/15/17.
Client #6 was admitted on 12/6/16 and was discharged on 2/3/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will meet with all RAW staff on March 30, 2018 to review the after care policy when a client is discharged successfully from any level of care. This policy and procedure will be reviewed in the next treatment team meeting to be held on April 4, 2018.
this policy will also be reviewed in weekly clinical supervision meetings next week on April 2, 2018.
The clinical supervisor will go over in Care Logic how to document after care follow up. |