INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 2, 2007 through July 3, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 28, 2007.
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Plan of Correction
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
The facility failed to provide an annual audit of financial activities for the July 2005 to June 2006 fiscal year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The facility failed to address 4 Pa. Code 255.5 as it relates to the release of client identity and client records to criminal justice agencies. A policy within the facility's policy and procedure manual stated that "a discharge summary is to be released to the client's probation officer, parole officer, or representative of the court on the day of the client's discharge". The information contained in the discharge summary exceeded what is allowable by 4 Pa. Code 255.5.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The drug and alcohol history failed to include the length and patterns of the clients' use throughout the course of their addiction in five of five client records reviewed, #1, 2, 3, 7 and 8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The individual treatment and rehabilitation plans failed to include goals stated in terms of measurable criteria in four of four client records reviewed, #1, 2, 3 and 8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Treatment plan updates failed to include an assessment of progress in relationship to the previously stated goals in five of five client records reviewed, #1, 3, 5, 6 and 8.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.94(f)(1) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(1) Identifying persons in need of project services.
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Observations
The facility failed to develop an outreach plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.94(f)(2) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(2) Alerting persons and their families to the availability of project services.
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Observations
The facility failed to develop an outreach plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.94(f)(3) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(3) Encouraging persons to utilize the service delivery system.
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Observations
The facility failed to develop an outreach plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |