INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 25, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Centre Counseling Associates 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 December 31, 2008.
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Plan of Correction
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709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
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Observations
Based on a the review of administrative records, the facility failed to document written letters of agreement with primary referral sources.
The findings include:
On November 25, 2008 administrative records were reviewed. The facility did not document any letters of agreement with primary referral sources.
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Plan of Correction
The Facility Director will within 60 days contact and request letters of agreement with the primary client referral sources. Upon receipt of such letters the documents shall be placed and retained within the facility's Policy and Procedure Manual. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of service in one of one client records.
The findings include:
One client record was reviewed on November 25, 2008. A record of service was required in one record. The facility did not document a record of service for client record # 3.
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Plan of Correction
The Facility Director shall document in the Policy and Procedure Maunual that all client records shall have a separate form contained within the file stating and recording the dates of service, the type of service and the length of service for each client session. These forms shall be included in all current client files and in all future client files. |