INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 5, 2007 and December 6, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection Parkside Recovery 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 January 3, 2008.
|
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
The facility failed to complete psychosocial evaluations. A review of client records on December 6, 2007 verified evaluations were not completed as required in the treatment management procedures in two of eight active client records reviewed.
|
Plan of Correction
The project was not in compliance with this standard due to an oversight on the part of the Primary Counselor and Clinical Supervisor in charge of the client record. The project will be in full compliance with this standard as of 12/31/07 by way of review of the treatment management procedures related to this standard during the next monthly staff clinical team meetings on 12/31/07 and subsequent follow-up as listed below.
The project will require the Clinical Supervisor to present the Primary Counselor with a signed copy of a Counselors Assignment Sheet indicating the due date of the client's psychosocial evaluation. The Clinical Supervisor will then document the information onto the Treatment Plan Update (TPU) tracking tool for additional follow-up during the Primary Counselors weekly clinical supervision session for compliance with this standard.
The Program Director will be responsible for consulting with the Clinical Supervisor for follow-up and continuity in this process.
|
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
The facility failed to complete case consolation notes. Five of sixteen client records reviewed on December 5, 2007 did not have documentation of case consultation notes as required in the organizational treatment management procedures.
|
Plan of Correction
The project was not in compliance with this standard due to an oversight on the part of the Primary Counselor and Clinical Supervisor in charge of the client record. The project will be in full compliance with this standard as of 12/31/07.
The project will require the Clinical Supervisor to present the Primary Counselor with a list of all case consultations that are due for the month, at the beginning of each month, via the Treatment Plan Update (TPU) tracking tool.
Primary Counselor will be responsible for completing all case consultations according to the due date listed on the TPU tracking tool and then forward the completed document to the Clinical Supervisor to be reviewed and signed off on during the Primary Counselors weekly clinical supervision session.
The Program Director will be responsible for consulting with the Clinical Supervisor for follow-up and continuity in this process.
|
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
The facility failed to maintain a complete client record. Six of eight discharged client records reviewed on December 6, 2007 did not include follow-up information as required in the organizational treatment management procedures.
|
Plan of Correction
The project was not in compliance with this standard due to an oversight on the part of Clinical Supervisor responsible for the discharged client record. The project will be in full compliance with this standard as of 12/31/07.
The project will require the Clinical Supervisor responsible for the discharged client record to track and follow up on the disposition of the referral via a Client Discharge Spreadsheet tracking tool for transferred clients on a weekly basis to ensure compliance in this area. The Program Director will be responsible for consulting with the Clinical Supervisor for follow-up and continuity in this process.
|