INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the December 9, 2011 licensing inspection.
The follow-up inspection was conducted on June 15, 2011 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the onsite follow-up inspection, Treatment Trends Inc. Keenan House, 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 follow-up inspection.
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Plan of Correction
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709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
Based on an onsite follow-up inspection on June 15, 2011 the facility failed to have complete client records on an individual which includes information relative to the client's involvement with the project.
The findings include:
The following citation was a repeat citation from the December 9, 20110 inspection. Five client records were reviewed at the onsite follow-up inspection. Five of five client records reviewed failed to have completed record of service included.
Record #1 was admitted on 05-05-2011. Group notes dated 05-27-2011, 05-17-2011, 05-14-2011, 05-06-2011 and 06-02-2011 were documented in the client record, however no record of service was included in the client record.
Client record #2 was admitted 05-02-2011. There were progress notes included in the client record for 05-06-2011, 05-13-2011, 05-27-2011, 05-20-2011 and 05-22-2011. There was no documentation of these services in the record of service.
Client #3 was admitted on 04-14-2011. There was no documentation in the client record from 04-14-2011 until 06-15-2011 inclusive of any services provided to this client.
Client #4 was admitted on 02-18-2011. No record of service was included in the client record from 04-14-2011 through 05-20-2011. Documentation in the client record stated there was no counselor available for service through this period of time.
Client record #5 had documentation in the progress notes of treatment services provided, however no record of service was documented for 05-04-2011, 05-24-2011, 05-19-2011, 05-12-2011 and 05-03-2011.
This is a repeat citation from the December 9, 2010 inspection.
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Plan of Correction
It has been noted that case management is increasingly complex and time consuming and are approved for treatment for shorter periods of time. As noted, the issue is not that paperwork is not complete, but counselors in their efforts to meet growing client need are not placing paperwork in the file in a timely manner. As of July 5th we have hired a full time overnight Clinical Technican whose duties include chart filing to ensure paperwork is filed once it passes through the paperwork checking systems that are currently in place. The Clinical Director will ensure Client Records are placed in each client chart in a timely fashion. This plan of correction is currently in operation as of Auagust 3, 2011. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on client record documentation reviewed on the June 15, 2011 follow-up inspection, the facility failed to complete progress notes for the record of service dates provided.
The findings include:
Five client records were reviewed on the onsite follow-up inspection, conducted on June 15, 2011. The facility failed to complete progress notes from the record of service documented in the client records. Five records were reviewed. Five of five client records required progress notes. Four of five client records were missing progress notes according to the record of service.
Client #1 was admitted on 05-05-2011. The record of service had documentation for 05-10-2011. The facility failed to have a progress note to reflect this service.
Client #2 was admitted on 05-02-2011. The facility failed to document a progress note for the record of service dated on 05-27-2011.
Client #3 was admitted on 04-14-2011. The facility failed to have progress notes documented from 04-14-2011 through 6-15-2011.
Client #4 was admitted on 02-18-2011. The facility failed to document progress notes from 04-14-2011 through 05-24-2011. Client record # 4 contained documentation there was no counselor available for this client to receive service.
This is a repeat citation from the 12-9-2011 licensing inspection.
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Plan of Correction
The Director of Vocational Counseling will work with the new Clinical Technician who is estimated to be hired, completed with HR and on the schedule by July 18, 2011. This new hire will be responsible to ensure that paperwork completed by the counseling staff is placed in the client files in a timely fashion. |