INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 2, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mercy Behavioral Health 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to provide a written procedure on designating a timeframe for the comprehensive treatment plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pittsburgh Mercy has reviewed our existing procedures and revised to include all current regulations and best practices. This procedure has been added to our new employee onboarding materials and has been distributed to all current staff.
Supervisors will ensure compliance with procedure during applicable supervisions and/or team meetings.
The revised procedure has been immediately released and POC is affective immediately.
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