INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 13-14, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Service and Children's Aid Society 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 11, 2009.
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Plan of Correction
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709.91(b)(6) LICENSURE Intake and admission
709.91. 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 a psychosocial evaluation that included a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms and negative factors in four of nine client records.
Eleven client records were reviewed on October 13-14, 2009. Nine client records were reviewed for documentation of a psychosocial evaluation. In client records # 2, 4, 6 and 7, the psychosocial evaluations failed to provide an evaluative summary but instead consisted of client reported problems/needs, assets/strengths, support systems, coping mechanisms and negative factors.
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Plan of Correction
A mandatory staff meeting will be held on November 2, 2009. Both the program director (facility director) and the clinical supervisor will review this finding with the clinical staff. The clinical supervisor will pull a minimum of 2 charts for each counselor and counselor assistant every 3 months to monitor ongoing compliance. The clinical supervisor has already met with the counselor assistant and the counselor at this site to review the psychosocial assessment form. All psychosocial assessments will be provided in an evaluative summary (clinical) and will not have any client reporting of client needs, assets/strengths, support systems, coping mechanisms and negative factors.
Completion Date: November 2, 2009 |
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.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan that included goals with time frames and support systems in three of three client records.
The findings include:
Eleven client records were reviewed on October 13-14, 2009. Aftercare plans were required in three client records. The aftercare plans did not identify support systems nor time frames in which the identified goals were to be completed in client records #8, 9 and 10.
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Plan of Correction
A mandatory staff meeting will be held on November 2, 2009. Both the program director (facility director) and the clinical supervisor will review this finding with the clinical staff. The clinical supervisor will randomly pull a minimum of 2 charts for each counselor and counselor assistant every 3 months to monitor compliance. All Aftercare Plans will identify specific goals with support systems and time frames listed.
Completion Date: November 2, 2009 |