INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Snyder 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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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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 document treatment plans to include the type and frequency of treatment services in four of eight client records reviewed.
The findings include:
Eight client records were reviewed for comprehensive treatment plans, which included the type and frequency of treatment services on June 16, 2015. Four out of eight client records lacked documentation of a treatment plan that included a the type and frequency of treatment services, specifically records # 3, 4, 5, and 8.
The comprehensive treatment plan for client #3 was documented on March 31, 2015; however it did not include the type and frequency of treatment services for client #3.
The comprehensive treatment plan for client #4 was documented on April 23, 2015; however it did not include the type and frequency of treatment services for client #4.
The comprehensive treatment plan for client #5 was documented on May 27, 2015; however it did not include the type and frequency of treatment services for client #5.
The comprehensive treatment plan for client #8 was documented on November 28, 2014; however it did not include the type and frequency of treatment services for client #8.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will be retrained by the Facility Dirctor and Corpoate Clinical Director on how to prepare their client master treatment plans regarding the proper scheduling of group time lines for the frequency of group attendance requirement. Counselors have been instructed upon current clients charts treatment plan updates to revise the treatment plans to include a group frequency schedule. The Clinical Supervisor and Facility Director will conduct monthly chart audits to ensure compliance with standard. |
709.52(a)(3) LICENSURE Support service type
709.52. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include proposed types of supportive services in seven of eight client records reviewed.
The findings include:
Eight client records were reviewed for comprehensive treatment plans, which included support services on June 16, 2015. Seven out of eight client records lacked documentation of a treatment plan that included a proposed type of support service, specifically records # 1, 3, 4, 5, 6, 7, and 8.
The comprehensive treatment plan for client #1 was documented on May 22, 2015; however it did not include a proposed type of support service for client #1.
The comprehensive treatment plan for client #3 was documented on March 31, 2015; however it did not include a proposed type of support service for client #3.
The comprehensive treatment plan for client #4 was documented on April 23, 2015; however it did not include a proposed type of support service for client #4.
The comprehensive treatment plan for client #5 was documented on May 27, 2015; however it did not include a proposed type of support service for client #5.
The comprehensive treatment plan for client #6 was documented on January 14, 2015; however it did not include a proposed type of support service for client #6.
The comprehensive treatment plan for client #7 was documented on January 14, 2015; however it did not include a proposed type of support service for client #7.
The comprehensive treatment plan for client #8 was documented on November 28, 2014; however it did not include a proposed type of support service for client #8.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and the Corporate Clinical Director will conduct a retraining session with all counselors on 6/30/2015 to discuss the proper documentation of support serives in the master treatment plans. Counselors have been instructed upon their clients treatment plan updates to amend the plans to include support systems activities that the facility conducts with clients on a daily basis. Counselors where instructed to include AA/NA meeting schedules in their treatment plans and show a frequency table time line in the treatment plans. The Clinical Supervisor and the Facility Director will conduct monthly chart audit to ensure compliance with standard. |