INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 20, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on January 12, 2007.
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
The program did not provide documentation of alternative exits being used during fire drills.
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Plan of Correction
Girard Medical Center did not properly document the use of alternative exits during fire drills.
Starting on 01-12-07, Girard Medical Center will properly document the use of alternative exits during fire drills.
Course of action: The Fire Marshall, has created new documentation procedure where he will ensure the proper documentation of the use of alternative exits in fire drills. The Fire Marshall will ensure that this process takes place during every fire drill conducted beginning 01/12/07.
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711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations did not include assets/strengths in six of seven records reviewed, # 2, 3, 4, 5, 6 and 7. The evaluations did not include an assessment of support systems in two of six records reviewed, # 3 and 4. Evaluations did not address coping/defense mechanisms in two of six records reviewed, # 1 and 5.
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Plan of Correction
IOP/CAP did not properly use the Psychosocial Evaluation. The evaluation has space to identify the different assets/strengths and coping/defense mechanisms as well to identify support systems and to explain why each system is adequate for the client's treatment. Counselors were not properly completing this form.
By 02-05-07, all the counselors will properly complete the Psychosocial Evaluation by identifying the different assets/strengths and coping/defense mechanisms as well by identifying and explaining why the support systems are adequate for the client's treatment.
Course of action is as follow: On 01-29-07, all the counselors will be trained on how to complete the entire evaluation. This will include the identification of the different assets/strengths and coping/defense mechanisms as well as to identification and explanation of why the support systems are adequate for the client's treatment. Beginning 01-30-07 the IOP/CAP clinical supervisor will review to verify for adequate completion of the evaluation and any evaluation that does not meet the requirement will be return to the counselor for correction.
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711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
The treatment plan did not include support services in six of seven records reviewed, # 1, 2, 3, 4, 6 and 7.
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Plan of Correction
IOP/CAP staff was not properly documenting the support services proposed in the client's treatment plans. IOP/CAP clinical supervisor was not reviewing for the completion of this area. IOP/CAP counselors were documenting these support services in progress notes but not in the treatment plans.
By 02-05-07, all the counselors will be documenting the proposed support services in the treatment plans.
Course of action is as follow: On 01-29-07 all the counselors will be trained on how to properly complete a treatment plan which will include the documentation of support services. Beginning 01-17-07, the clinical supervisor will review the treatment plans to ensure that the different support services are documented in the treatment plans. By 02-05-07, all the treatment plans will include the documentation of proposed types of support services.
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Treatment plan updates did not include a review of progress on previously stated goals in six of seven reviewed, # 2, 3, 4, 5, 6 and 7.
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Plan of Correction
IOP/CAP counselors were not properly reviewing the progress of previously stated goals on new treatment plans. Clinical supervisor was not reviewing for the proper completion of the update.
Starting 2-5-07, all updates will properly document the process of lack of there of any goal previously stated.
On 01-29-07, clinical supervisor will conduct an in-service were all the counselors will be trained on the proper completion of the update. Counselors will assess the client's progress or lack of there regarding the goals previously stated. Beginning 02-05-07, the clinical supervisor will monitor to ensure compliance of this procedure.
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