INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 2008 through July 30, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mazzitti and Sullivan Counseling Services 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 September 1, 2008.
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Plan of Correction
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of ten client records, one client record was required to have a notification of termination documented. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one client record reviewed, #9. The notification of termination was missing.
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Plan of Correction
The facility director will train staff on 9/19/08 regarding the notification of terminated clients,whether voluntary or not need to recieve notification of termination letters. On going UR under the supervision of the facility director |
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 a review of 10 client records on July 30, 2008, the facility failed to document a psychosocial evaluation in one of ten client records reviewed, #7. The facility failed to document a complete psychosocial evaluation in the remaining nine client records reviewed, #1, 2, 3, 4, 5, 6, 8, 9 and 10. The evaluation was a repeat of historical information gathered from the client and included very little relative to clinical impressions. The evaluation did not identify negative factors that may affect treatment. Client support systems were missing in five of the nine client records that had an evaluation, #1, 2, 6, 9 and 10. Support systems were client identified in two of the nine client records that had an evaluation, #4 and 8.
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Plan of Correction
The facility director will train staff on September 19 2008 on the psychosocial eval clinical impressions as determined by the Department of Health regs and reviewers comments. Ongoing UR under the supervison of the facility director will ensure compliance |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of ten client records on July 30, 3008, two records were required to have aftercare plans. The facility failed to document aftercare plans with measurable goals and specific time frames in two of two client records reviewed, #6 and 8. The goals were very general and not easily measurable and the time frames included "ongoing."
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Plan of Correction
The facility director and staff will review the Aftercare plan form to make changes that will allow for more specific and measureable objectives. ONgoing UR under the supervison of the facillity director will ensure compliance. Complete date 9/30/08 |
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 ten client records on July 30, 2008, five were required to have follow-up information. The facility failed to document follow-up information in two of five client records reviewed, #7 and 8.
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Plan of Correction
The facility director will train staff on completing follow-up on all clients whether voluntarily discharged or not. Ongoing UR under the supervison of the facility director will ensure compliance. Completion date 9/30/08 |