INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20-21, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Care Center dba SPHS - Waynesburg, 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 June 11, 2009.
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Plan of Correction
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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.
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Observations
Based on a review of client records, the facility failed to provide written documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plans, in three of ten client records.The findings include:Ten client records were reviewed on May 20-21, 2009. The individual treatment and rehabilitation plans were required to document type and frequency of services in ten client records. The facility did not document type and frequency of services in client records # 1, 2, and 3.
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Plan of Correction
The clinical supervisor and facility director will conduct an in-service training in July, 2009 regarding the appropriate development and documentation of treatment and rehabilitation plans, with specific attention given to the identification and documentaion of the type and frequency of support services to be included in individual treatment and rehabilitation plans.
Plans shall be reviewed by the clinical supervisor during individual staff supervision to insure complaince. |
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
Based on a review of client records, the facility failed to complete sixty day treatment plan updates in two of five client records.The findings include:Ten client records were reviewed on May 20-21, 2009. Sixty day treatment plan updates were required in five client records. The facility did not document treatment plan updates every sixty days in client records # 3 and 7.Client # 3 was admitted on June 6, 2008 and the comprehensive treatment plan was completed on July 23, 2008. A treatment plan update was due by September 23, 2009. Treatment plan updates were completed on October 1, 2008 and December 5, 2008.Client # 7 was admitted on February 2, 2009 and the comprehensive treatment plan was completed on February 23, 2009. A treatment plan update was due by April 23, 2009. A treatment plan update was completed on May 1, 2009.
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Plan of Correction
The clinical supervisor and facility director will conduct an in-service training in July, 2009 regarding the appropriate updating of treatment and rehabilitation plans. Specific attention will be given to the timely review and updating of individual treatment and rehabilitation plans, as well as documentation of same.
Plans shall be reviewed by the clinical supervisor during individual staff supervision to insure complaince. |
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 the review of client records, the facility failed to document follow up in one of one client records.The findings include:Ten client records were reviewed on May 20-21, 2009. Follow up was required in one outpatient client record. The facility did not document follow up in client record # 1.Client #1 was discharged on November 3, 2008 and follow up documentation was due by May 3, 2009. At the time of the inspection the follow up had not been completed.
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Plan of Correction
The clinical supervisor shall provide direct supervision to this staff person on the appropriate procedures regarding client follow-up and documentation. In addition, the clinical supervisor will conduct an in-service for all staff regarding the time frames, procedures and documentation for client follow-up.
Ongoing compliance will be the responsibilty of the clinical supervisor and shall be accomplished through regular chart review and supervision. |