INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard IOP-CAP 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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709.44(a)(1)(i) LICENSURE Medical History
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to include documentation of a completed medical history in the client records in five of seven client records reviewed.
Client #1 was admitted on November 21, 2022 and was discharged November 21, 2022. There was no medical history in the record at the time of the inspection.
Client #2 was admitted on February 22, 2023 and was discharged on February 22, 2023. There was no medical history in the record at the time of the inspection.
Client #3 was admitted on April 18, 2023 and was discharged on April 18, 2023. There was no medical history in the record at the time of the inspection.
Client #4 was admitted on June 13, 2023 and was discharged on June 13, 2023. There was no medical history in the record at the time of the inspection.
Client #5 was admitted on July 13, 2023 and was discharged on July 13, 2023. There was no medical history in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
BWC Physician will complete Medical Histories upon admission per DDAP requirements.
Supervisor will randomly review 5 new admission charts per month for 2 months for compliance of 100%. |
709.44(a)(1)(ii) LICENSURE Drug/Alcohol history
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to include documentation of a completed drug and alcohol history in the client records in five of seven client records reviewed.
Client #1 was admitted on November 21, 2022 and was discharged November 21, 2022. There was no drug and alcohol history in the record at the time of the inspection.
Client #2 was admitted on February 22, 2023 and was discharged on February 22, 2023. There was no drug and alcohol history in the record at the time of the inspection.
Client #3 was admitted on April 18, 2023 and was discharged on April 18, 2023. There was no drug and alcohol history in the record at the time of the inspection.
Client #4 was admitted on June 13, 2023 and was discharged on June 13, 2023. There was no drug and alcohol history in the record at the time of the inspection.
Client #5 was admitted on July 13, 2023 and was discharged on July 13, 2023. There was no drug and alcohol history in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
BWC Intake and/or Counselor will complete a Personal History in the Drug and Alcohol History (Bio Psychosocial) for new admissions within required time frames as mandated by DDAP.
Supervisor will randomly review 5 new admission charts per month for 2 months for compliance of 100%. |
709.44(a)(1)(iii) LICENSURE Personal history
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to include documentation of a completed personal history in the client records in five of seven client records.
Client #1 was admitted on November 21, 2022 and was discharged November 21, 2022. There was no personal history in the record at the time of the inspection.
Client #2 was admitted on February 22, 2023 and was discharged on February 22, 2023. There was no personal history in the record at the time of the inspection.
Client #3 was admitted on April 18, 2023 and was discharged on April 18, 2023. There was no personal history in the record at the time of the inspection.
Client #4 was admitted on June 13, 2023 and was discharged on June 13, 2023. There was no personal history in the record at the time of the inspection.
Client #5 was admitted on July 13, 2023 and was discharged on July 13, 2023. There was no personal history in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
BWC Intake and/or Counselor will complete a Personal History in the Drug and Alcohol History (Bio Psychosocial) for new admissions within required time frames as mandated by DDAP.
Supervisor will randomly review 5 new admission charts per month for 2 months for compliance of 100% |
709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to include a completed psychosocial evaluation in the client records in five of seven client records reviewed.
Client #1 was admitted on November 21, 2022 and was discharged November 21, 2022. There was no psychosocial evaluation in the record at the time of the inspection.
Client #2 was admitted on February 22, 2023 and was discharged on February 22, 2023. There was no psychosocial evaluation in the record at the time of the inspection.
Client #3 was admitted on April 18, 2023 and was discharged on April 18, 2023. There was no psychosocial evaluation in the record at the time of the inspection.
Client #4 was admitted on June 13, 2023 and was discharged on June 13, 2023. There was no psychosocial evaluation in the record at the time of the inspection.
Client #5 was admitted on July 13, 2023 and was discharged on July 13, 2023. There was no psychosocial evaluation in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
BWC Intake and/or Counselor will fully complete a Bio Psychosocial for new admissions within required time frames as mandated by DDAP.
Supervisor will randomly review 5 new admission charts per month for 2 months for compliance of 100% |