INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensure renewal inspection that was conducted on August 10, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Centre Counseling Associates 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 supervisory review and a plan of correction is due on December 20, 2012.
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Plan of Correction
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document the complete drug and alcohol history in one of one client records reviewed.
The findings include:
This facility has only one active client record. The client record was reviewed again during the licensing inspection conducted on 8/10/12. The drug and alcohol history in the client record failed to include the lengths and patterns of abuse, the client's prior treatment experiences, the client's perception of abuse and the client's family history of substance abuse.
Client # 1, the facility's only client, was admitted on 12/15/10. The client was in continuous active treatment up to the inspection conducted on 8/10/12. This client record had been found in non compliance in the past for the same deficiency. As of 8/10/12 there was no documentation in the client record that the drug and alcohol history had been updated.
This was reviewed with the sole proprietor and was not disputed.
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Plan of Correction
The Project Director shall review the file cited and upon the next session with the client shall include or update the appropriate drug and alcohol history as per the cited deficiencies. A complete history shall be included in all future client files. |
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 a review of client records, the facility failed to document the complete personal history in one of one client records reviewed.
The findings include:
This facility has only one active client record. The client record was reviewed again during the licensing inspection conducted on 8/10/12. The personal history in the client record failed to include the client's family history, legal history, employment/vocational history, educational history, military history, recreational history and the sexual history.
Client # 1, the facility's only client, was admitted on 12/15/10. The client was in continuous active treatment up to the inspection conducted on 8/10/12. This client record had been found in non compliance in the past for the same deficiency. As of 8/10/12 there was no documentation in the client record that the personal history had been updated.
This was reviewed with the sole proprietor and was not disputed.
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Plan of Correction
The Project Director shall review the cited file and upon the next session with the client update all of the client's family history, legal history, employment/vocational history, educational history, military history, recreational history and the sexual history. This information will be included in all future treatment files. Time frame 30 days.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document the individual treatment and rehabilitation plan developed with the client in one of one client records reviewed.
The findings include:
This facility has only one active client record. The client record was reviewed again during the licensing inspection conducted on 8/10/12. There was no documentation of the individual treatment and rehabilitation plan developed with the client in the client record.
Client # 1, the facility's only client, was admitted on 12/15/10. The client was in continuous active treatment up to the inspection conducted on 8/10/12. This client record had been found in non compliance in the past for failure to document the individualized treatment and rehabilitation plan. As of 8/10/12 there was no documentation in the client record that an individualized treatment and rehabilitation plan had been developed with the client.
This was reviewed with the sole proprietor and was not disputed.
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Plan of Correction
The Project Director shall review the cited file and upon the next session with the client update the client's individual treatment plan including the required parameters.
Time frame 30 days. |