INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6-7, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Recovery Revolution, 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.
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Plan of Correction
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709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documents, the facility policy and procedure manual and an interview with the Project Director, the facility failed to document annual goals and objectives for the 2012-13 year.
The finding includes:
The annual onsite licensing inspection was conducted on March 6-7, 2013. There was no documentation of annual project goals and objectives for fiscal year 2012-2013.
An interview with the project director on March 6, 2013 confirmed that the goals and objectives had not been completed and approved by the governing body.
The finding was reviewed with the project director and was not disputed.
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Plan of Correction
Executive Director acknowledges that this was overlooked in past year due to putting a new 4 year plan into place. At the board meeting on March 28th, 2013 the Executive Director will bring Goals and Objectives for 2012-2013 year for review and vote. In addition, the Executive Director will bring prior to July 1, the goals for the upcoming year and review the past goals at which time our Board of Directors will vote on both past and future goals. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to document complete personal histories in eight of eight client records reviewed.
The findings include:
The annual onsite licensing inspection was conducted on March 6-7, 2013. Eight of eight client records failed to include documentation of the clients' complete personal history.
Client record #1 - This client was admitted on 6/26/12 and discharged on 2/7/13. The personal history in this record failed to include documentation of the client's family interactions and legal history
Client record #2 - This client was admitted on 5/3/12 and discharged on 9/21/12. The personal history in this record failed to include documentation of the client's family interactions, employment history, educational history and sexual history.
Client record #3 - This client was admitted on 2/28/12 and last treated on 3/1/13 . The personal history in this record failed to include documentation of the client's family relationships, employment, educational and sexual histories.
Client record # 4- This client was admitted on 10/11/12 and last treated on 3/4/13. The personal history in this record failed to include documentation of the client's educational history and recreational interests.
Client record #5 - This client was admitted on 10/17/12 and last treated on 3/5/13. The personal history in this record failed to include documentation of the client's family relationships and educational history.
Client record #6 - This client was admitted on 2/25/13 and last treated on 3/6/13. The personal history in this record failed to include documentation of the client's family relationships and educational history.
Client record # 7- This client was admitted on 10/29/12 and last treated on 2/7/13. The personal history in this record failed to include documentation of the client's family relationships and employment history.
Client record #8 - This client was admitted on 8/27/12 and last treated on 2/24/13. The personal history in this record failed to include documentation of the client's family relationships and employment history.
The findings were reviewed with the project director and were not disputed.
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Plan of Correction
The Executive Director will meet with all clinical staff on March 26th at 1pm regarding filling out the biopsychosocial fully to include the personal histories. They will be reminded to answer all the questions and put more than one word answers. In addition, the clinical supervisor upon review of clinical charts will be reviewing that this is being done prior to signing off on them. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation which addressed the clinical impressions of the counselor on the psychosocial evaluations in seven of eight client records.
The finding includes:
The annual onsite licensing renewal inspection was conducted March 6-7, 2013. Seven of eight psychosocial evaluations were not evaluative, failing to identify the possible causes, relationships and conditions leading to the client's current situation.
Client record #1 - This client was admitted on 6/26/12 and discharged on 2/7/13. The psychosocial evaluation failed to identify the clinical impressions of the counselor which identified relationships, causes and conditions leading to the client's current situation.
Client record #2 - This client was admitted on 5/3/12 and discharged on 9/21/12. The psychosocial evaluation failed to include the clinical impressions of the counselor which identified relationships, causes and conditions leading to the client's current situation.
Client record #3 - This client was admitted on 2/28/12 and last treated on 3/1/13 . The psychosocial evaluation failed to include the clinical impressions of the counselor which identified relationships, causes and conditions leading to the client's current situation.
Client record # 4- This client was admitted on 10/11/12 and last treated on 3/4/13. The psychosocial evaluation failed to include the clinical impressions of the counselor which identified relationships, causes and conditions leading to the client's current situation.
Client record #5 - This client was admitted on 10/17/12 and last treated on 3/5/13 . The psychosocial evaluation failed to include the clinical impressions of the counselor which identified relationships, causes and conditions leading to the client's current situation.
Client record # 7- This client was admitted on 10/29/12 and last treated on 2/7/13 . The psychosocial evaluation failed to include the clinical impressions of the counselor which identified relationships, causes and conditions leading to the client's current situation.
Client record #8 - This client was admitted on 8/27/12 and last treated on 2/24/13. The psychosocial evaluation failed to include the clinical impressions of the counselor which identified relationships, causes and conditions leading to the client's current situation.
The findings were reviewed with the project director and were not disputed.
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Plan of Correction
Upon review, the psychosocial form will include a minor change to add a section of writing to address clinical impressions that are not documented well by the current form. At the clinical meeting on March 26th, 2013, the Executive Director will be giving out the new form and addressing with staff that it needs to be filled out completely and thoroughly.
Upon the QI process that has been identified, the supervisor will be reviewing all psychosocial evaluations prior to signing them to make sure that they are upheld to this standard. |