INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 14 through 15, 2008 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 12, 2008.
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Plan of Correction
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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
Based on a review of eight client records on October 14 through 15, 2008, facility failed to document a psychosocial evaluation in five of eight records reviewed, as required.Findings:In client records, #2, 3, 5, 6 and 8, the psychosocial evaluation was based on client reported comments with a list of adjectives for each identified area and did not provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
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Plan of Correction
The Clinical Director will hold a supervision training session with all Clinicians where the need to provide a composite picture of the individual will be stressed. Clinicians will learn to document more than client reported comments.
The psychosocial evaluation will be a focus of the quarterly record review performed by the Clinical Director. |
711.92(c)(1) LICENSURE TX Plan Goals
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:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Based on a review of eight client records on October 14 through 15, 2008, facility failed to document short and long-term goals for treatment in four of six records reviewed, as required.Findings:In client records, #2, 4, 5 and 8, the short and long-term goals for treatment were identical and did not address specific individual needs as identified by the both staff and client, as required.
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Plan of Correction
A training session will be held by the Clinical Director with all Clinicians to assure the understanding of the need to individualize short and long term goals to each client.
Random charts will be reviewed quarterly by the Clinical Director to assure individualization. |
711.93(a)(6) LICENSURE Aftercare Plans
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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of eight client records on October 14 through 15, 2008, facility failed to document aftercare plans in two of two records reviewed, as required.Findings:In client records, #4 and 5, the aftercare plans did not include documented timeframes for individual goals nor identified support services to be utilized by the client, as required.
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Plan of Correction
The Clinical Director will hold a supervision training session with all Clinicians to assure they understand that both timeframes for individual goals and identified support services must be documented on each aftercare plan.
Aftercare planning will be audited by the Clinical Director quarterly. |