INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 1- 3, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Butler Regional Recovery Day Program 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 May 1, 2008.
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Plan of Correction
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711.91(b)(3)(iii) LICENSURE Personal History
711.91. 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 review of client records during the licensing inspection on April 1-3, 2008, the personal history is incomplete in client records # 2, 3 and 4. In client record # 2 the employment history consisted only of questions with a "yes", but none of the employment history was documented. The family history consisted of documentation that was contradictory in client records #2, 3 and 4. Employment documentation in client record # 3 was contradictory. The education history in record # 2 was incomplete, failing to provide clarification on one word responses such as "normal". The family and employment history was contradictory and the legal history was incomplete in client record #3. The employment history, sexual history and family history in client record #4 was incomplete.
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Plan of Correction
AS OF 4/11/08 COUNSELORS WILL REVIEW THE PSYCHOSOCIAL IN MORE DETAIL. THEY WILL RECORD THE ADDED DETAIL ON THE PSYCHOSOCIAL AS THE CLIENT EXPANDS THE INFORMATION GIVEN. THE CLINICAL SUPERVISOR WILL ENSURE THIS PROCESS BY CONDUCTING MONTHLY CHART REVIEWS FOR THE NEXT 3 MONTHS. |
711.93(a)(4) LICENSURE Progress Notes
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(4) Progress notes.
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Observations
Based on review of client records during the licensing inspection on April 1- 3, 2008, the group progress notes were weekly summaries of various group sessions, which is contrary to the requirement that weekly summaries of group sessions only be used for groups with the same topics presented and facilitated by the same counselor. In client records # 2 and 3 and 4, the group progress notes were documented with daily data summaries, but were documented with different topics. At the end of the week one weekly summary was documented for all of the diverse group sessions conducted.
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Plan of Correction
AS OF 4/11/08 THE COUNSELOR WILL DOCUMENT A DAILY GROUP NOTE IN DATA, ASSESSMENT, PLAN FORMAT. THE CLINICAL SUPERVISOR WILL MONITOR THIS PLAN THROUGH MONTHLY CHART REVIEWS FOR THE NEXT 3 MONTHS. |