INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 9 through 10, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Path Incorporated 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 May 2, 2008.
|
Plan of Correction
|
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a April 10, 2008 review of client records, the facility failed to document the frequency of individual treatment on the treatment plan in three of eight records reviewed, # 3, 6 and 7. Client records # 3 and 6 stated individual treatment was to be conducted as needed. Client record # 7 stated individual treatment was to be conducted weekly with no qualifying numerical value for how often weekly.
|
Plan of Correction
The program director has trained all staff re: specifying the frequency of treatment on the treatment plan. The program director,who reviews and signs all treatment plans,will ensure frequency is correctly documented during the review process. The training occurred on 4/17/2008. Follow-up(ie review process) is ongoing. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a April 10, 2008 review of client records, the facility failed to document a complete aftercare plan in one of two client records reviewed, # 11. Aftercare plans were missing goals with time frames and the re-entry process.
|
Plan of Correction
The program director has provided retraining for all staff re: proper completion of the aftercare plan, including goals with timeframes and the reentry process. Training occurred on 04/17/2008. |