INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 13-14, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Service and Children's Aid Society 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 November 11, 2009.
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Plan of Correction
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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.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan that included goals with time frames and support systems in two of two client records.
The findings include:
Eight client records were reviewed on October 14, 2009. Aftercare plans were required in two client records. The aftercare plans did not identify support systems nor time frames in which the identified goals were to be completed in client records # 5 and 6.
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Plan of Correction
A mandatory staff meeting will be held on November 2, 2009. Both the program director (facility director) and the clinical supervisor will review this finding with the clinical staff. The clinical supervisor will pull a minimum of 2 charts for each counselor and counselor assistant every 3 months to monitor ongoing compliance. All Aftercare Plans will identify specific goals with support systems and time frames listed.
Completion date: November 2, 2009 |