INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 1, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Human Services Administration Organization, 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:
|
Plan of Correction
|
709.42(b)(2) LICENSURE Preliminary Treatment Plan
709.42. Project management.
(b) The intake project or treatment service providers shall have a written procedure for the performance of the following functions:
(2) Preparation of a preliminary treatment plan utilizing appropriate available service resources and listing the services to be provided. This plan shall be developed in cooperation with and agreed to by the intake project or treatment service provider and the client. The service plan shall also include referral to services not specifically for drug and alcohol clients; for example, legal services and dental services for which the client may be eligible.
|
Observations
The facility failed to document the preparation of a preliminary treatment plan in three of three client records reviewed on March 1, 2018.
Client records # 1, 2 and 3 were missing documention of a preliminary treatment plan.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
For purposes of establishing an identified preliminary treatment plan, the Intake/Assessor personnel will document the recommendation at the conclusion of their biopsychosocial assessment.
To ensure compliance, the IMPACT Supervisor will review all documentation upon the completion of an assessment as it is the Supervisor's responsibility for staff oversight.
To date, existing staff are trained on documentation and therefore it is not believed that these changes will require any additional training.
Facility to be in full compliance with this standard as of 3/5/18.
|
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
|
Observations
The facility failed to document a consent to treatment in three of three client records reviewed on March 1, 2018.
Client records # 1, 2 and 3 were missing documention of a consent to treatment.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A 'Consent to Treatment' form will be created that will outline an individual's general consent to services if recommended. This form will be utilized at each assessment as the Intake/Assessor personnel will be responsible for ensuring it is signed. Should an individual refuse to sign this form then that will be documented as part of the observations from the assessment.
The utilization of this form will be discussed with staff (completed on 3/2/18) and the form will be implemented. Ongoing oversight to ensure compliance will be monitored by the IMPACT Supervisor.
Facility to be in full compliance with this standard as of 3/7/18.
|
709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
|
Observations
The facility failed to document a psychosocial evaluation in three of three client records reviewed on March 1, 2018.
Client records # 1, 2 and 3 were missing documention of a psychosocial evaluation.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
After each completed assessment staff will document their conclusions to capture their psychosocial evaluation of the individual.
To ensure compliance, the IMPACT Supervisor will review all documentation upon the completion of an assessment as it is the Supervisor's responsibility for staff oversight.
To date, existing staff are trained on documentation and therefore it is not believed that these changes will require any additional training.
Facility to be in full compliance with this standard as of 3/5/18.
|