INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25. 2007 to June 27, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on July 24, 2007.
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Plan of Correction
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709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to comply with the restrictions on the amount and type of information that could be released, with or without the clients consent, in accordance with 4 Pa. Code Subsection 255.5(b). The information listed on the PA Client Placement Criteria (PCPC) documents exceeded the restrictions relative to the legal information and information relating to treatment issues. In one chart a release failed to identify who would be receiving the information which then caused the restrictions imposed at 255.5(b) to be applicable.
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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. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
The facility failed to inspect the drug storage area with the frequency dictated by faculty policy and procedure.
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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. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. 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 facility failed to ensure that Drug and/or alcohol histories included the client's lengths and patterns of use/abuse in four out of five client records reviewed, # 1, 2, 3, 4, and 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. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The facility failed to ensure that the data collection forms for the personal histories collected all required information in reference to employment, educational, recreational, and sexual histories
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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. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
The facility failed to ensure that treatment plan goals were individualized. Treatment plans reviewed contained similar objectives/action steps in three out of three client records reviewed, # 1, 3, and 4.
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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. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The facility failed to ensure that treatment plan goals and objectives were realistic and measurable in three of three client records reviewed, # 1, 3 and 4.
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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. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Treatment plan updates contained a review of progress on previously stated gaols, but
The facility failed to provide for treatment plan updates that contained an indication of the client's progress in treatment, in relation to the stated goals and objectives for the period under review. The progress was similar or the same from update to update. The updates failed to identify what changes had taken places since the previous update.
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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. |