INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 28, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Addictive Diseases - Main Line Affiliates 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 November 30, 2009.
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Report", the Project Director job description and an interview with the current Project Director, the facility failed to ensure that the person appointed as the project director reported to the Board of Directors.
The findings include:
The current Project Director does not report directly to the Board of Directors and does not have the authority to set wage and salary scales. The current Project Director reports to an intermediary, who in turn reports to the Chief Executive Officer, who then reports to the Board of Directors.
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Plan of Correction
An exception will be requested according to procedure. If an exception is not granted, the CEO will be named Project Director. |
711.91(b)(3)(i) LICENSURE Medical History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of eight client records the facility failed to document histories which included the medical history of the client's family in five of eight client records.
Findings:
On October 28, 2009, a review of eight client records was conducted during the annual onsite inspection. Of the eight client records, the client's medical history did not include documentation of the family medical history in client records # 2, 3, 4, 6, and 7.
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Plan of Correction
A new medical screening tool will be developed and given to the clients upon evaluation which will include the family medical history. Additionally, the Clinical Director will review with all Counselors during team meeting on 12/1/2009 the expected documentation for the medical history, including family medical history. The Clinical Director will collect data on the completion of the family medical history during quarterly chart audits |
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
Based on the review of client records, the facility failed to document psychosocial evaluations that included an evaluation of client assets and strengths, support systems, coping mechanisms, negative factors that may affect response to treatment and the client's attitude toward treatment.
Findings:
On October 28, 2009, eight client records were reviewed for psychosocial evaluations. Client records # 1, 2, 3, 4, 5, 6, 7 and 8 contained psychosocial evaluations which did not include evaluations of the clients' assets and strengths, coping mechanisms and negative factors affecting response to treatment. The psychosocial evaluations in client records # 1, 2, 3, 4, 5, 6, 7 and 8 contained little to no description and no evaluation of the clients' support systems.
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Plan of Correction
The Clinical Director will review with all Counselors during team meeting on 12/1/2009 the expected documentation for the psychosocial evaluation including the clients' assets and strenghts, coping mechanisms and negative factors affecting response to treatment. The Clinical Director will collect data on the accurate completion of the psychosocial evaluations during quarterly chart audits. |