INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 27, 2008 through October 30, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A Better Today, 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 December 4, 2008.
|
Plan of Correction
|
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
|
Observations
Based on a physical plant inspection on October 30, 2008, the facility failed to ensure the exhaust fans were operable.
Findings:
The exhaust fans in the male and female bathrooms used by clients, staff, and other visitors to the facility were found to be inoperable at the time of the physical plant inspection.
|
Plan of Correction
P201
The Excecutive Director will contact the landlord at the Hazleton facility and request that the exhaust fans in the male and female bathrooms used by clients, staff, and other visitors to the facility be checked by the maintenance department and repaired if necessary so that they are in an operable condition. Time frame 30 days. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of four client records on October 28, 2008, the facility failed to document a complete psychosocial evaluation for two of three clients, where required, #1 and 2.
Findings:
The facility did not document a psychosocial evaluation to include the client's assets/strengths that can contribute to treatment in client records #1 and 2.
The facility did not document a psychosocial evaluation to include the client's potential or available support systems in client records #2.
The facility did not document a psychosocial evaluation to include the client's preferred coping mechanisms in client records #1 and 2.
|
Plan of Correction
1871
The Executive Director will instruct the Clinical Supervisor to ensure that counselors document psychosocial evaluation to include the client's assets/strengths that can contribute to client's treatment as required in 709.91 (6). Clinical Supervisor will conduct in house training sessions with clinical staff and client charts will be reviewed bu Clinical Supervisor,randomly, on a monthly basis.Timeframe 10 days |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of four client records on October 28, 2008, the facility failed to complete a case consultation note in one of one record where a case consultation note was required.
Findings:
The facility failed to document a case consultation note for client record #3, which was due by June 30, 2008.
|
Plan of Correction
1905
The Executive Director will instruct the Clinical Supervisor to ensure that the couselors document case consultation notes for all clients within 90 days of the evaluation and 90 days thereafter. The Clinical Supervisor at the weekly clinical staff meeting will instruct clinial staff this needs to be done. Clinical Supervisor will inspect client charts on a bi-monthly basis to ensure this is done. Timeframe - 30 days
|