INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16, 2008 through September 17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cora Services Inc. 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 October 20, 2008.
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Plan of Correction
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of the facility's policy and procedure manual on September 16, 2008 and a review of eight client records on September 18, 2008, the facility failed to document follow-up information in four of four client records where required.
Findings:
The facility's policy and procedure states that all follow-up attempts will be completed within 30 days of discharge and 90 days of discharge for clients who are not being referred on for more treatment. The facility failed to have documentation of attempts to follow up on the client in client records #5, 6, 7 and 8.
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Plan of Correction
The CSD Director will clarify the Agency's policy and procedures regarding follow-up activities and documentation of same to ensure compliance. The CSD Clinical Coordinator will retrain all staff on proper implementation of revised procedures. CSD Clinical Supervisors will monitor counselor follow-up actions and documentation. Effective date of action is 10/10/08. |