INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 30, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Treatment Trends Inc. Confront 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:
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Plan of Correction
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation and a physical plant inspection, the facility failed to secure discharged hard copy client records within locked storage containers.The findings include:A physical plant inspection was completed on December 30, 2015. At the time of the physical plant inspection, the discharged client records were located in a basement office closet. The closet was unlocked, and the file cabinets within the closet were also unlocked.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Files will be secured under a doubled locked process including the file room door and the existing filing cabinet. Keys to both the door and filing cabinets will be secured by the program director, administrative assistant, and lead counselor of the facility. Access granted to the files will include the program director, administrative assistant, lead counselor, and filing clerk of the agency. Their will be a sign out and sign in sheet for tracking of keys and times. Upon returning and signing of keys the filing clerk will check that file cabinets and filing room door are secure. A revolving schedule will be posted including the program director, administrative assistant, lead counselor, and filing clerk to check and sign off 3 times daily including upon opening and closing that the locks are secure. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a client record which included a consent to treatment, medication records, record of services, progress notes, case consultations, and/or discharge summary in two of seven client records.The findings include:Seven client records requiring documentation of consent to treatment, medication records, record of services, progress notes, case consultations, and discharge summary were reviewed December 30, 2015.The facility failed to document a record of service or a discharge summary in client record # 3. Client #3 was admitted on June 12, 2015 and was discharged on September 15, 2015. The client record did not contain a record of service or a discharge summary.Additionally, the facility failed to document a record of service, a case consultation, or a discharge summary in client record # 4. Client #4 was admitted on April 13, 2015 and was discharged on September 15, 2015. The client record did not contain a record of service, a case consultation or a discharge summary.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate implementation will include a document checklist in all client's charts. Counselors will be responsible for completing the checklist and signing off for dates of completed documentation. Staff will be reviewing their charts and checklists during weekly supervision for all due paperwork. Three monitoring points will be implemented using the program director, lead counselor, and supervision for documentation done in a timely fashion, all documentation in the chart by due dates, and all signatures required on the documentation. This process will also include a discharge monitoring process by which the counselor and supervisor will review the chart for all completed documentation before a discharge status will be approved. |