INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 13, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Roxbury 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 March 20, 2009.
|
Plan of Correction
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to complete psychosocial evaluations in six of six client records.
Findings:
Six client records were reviewed on February 13, 2009. Psychosocial evaluations were required in six client records. The psychosocial evaluations had listed responses and client stated comments rather than a clinical assessment of the client, clients problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, clients attitude toward treatment and the counselors impression/impression of the client in client records #1, 2, 3, 4, 5 and 6.
|
Plan of Correction
The Director of Outpatient Services will facilitate a training session with all pertinent staff on 3/17/09. This training will educate staff on the importance of completing the psychosocial evaluation from the clinician's perspective, with emphasis on covering all the recommended points. The clinician will be able to gather the needed information from the patient's self-assessment and form an evaluation from their own perspective. Random chart reviews will be performed to monitor ongoing completeness of psychosocial evaluations. Any identified deficiencies will be addressed through supervision and additional training as necessary. |
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.
|
Observations
Based on a review of client records on February 13, 2009, the facility failed to document complete an aftercare plan in two of three client records.
Findings:
Six client records were reviewed. Aftercare plan was required in three client record. Aftercare plan was not documented in records #4 and 6. Per the facilities policy and procedure all clients will receive a aftercare plan. Client record #4 was admitted on 8/1/08 and discharged on 9/8/08. Client record #6 was admitted on 9/25/08 and discharged on 12/2/08.
|
Plan of Correction
The Risk Manager is currently revising the aftercare policy. The revision will reflect that aftercare plans will not be required on any clients that have left treatment against project advice or refuse to participate in an aftercare plan. The policy will be completed by 3/23/2009. |