INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9, 2009 through February 12, 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 on March 13, 2009.
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Plan of Correction
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to complete psychosocial evaluations in five of seventeen client records.
The findings include:
Seventeen client records were reviewed on February 11, 2009 through February 12, 2009. Psychosocial evaluations were required in seventeen client records. The psychosocial evaluations had listed the client's self assessment and the client's comments rather than the counselor's evaluation of the client, the clients problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, and the counselor's evaluation of the clients attitude toward treatment and the counselor's impression/conclusions of the client in client records #8, 9, 10, 11 and 12.
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Plan of Correction
The Director of Clinical Services and the Director of Social Services will co-facilitate a training with all pertinent staff on 03/11/2009. This training will educate the staff on the importance of completing the psychosocial evaluation from the clinicians perspective. The clinician will be able to gather the needed information from the patients self-assessment and form an evaluation from their own perspective. The Director of Social Services will audit 20 charts weekly to ensure that the clinicians are completing an evaluation and not an assessment. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to complete psychosocial evaluations in seven of seventeen client records.
The findings include:
Seventeen client records were reviewed on February 11, 2009 through February 12, 2009. Psychosocial evaluations were required in seventeen client records. The psychosocial evaluations listed responses from the client and the client's self assessment rather than a clinical assessment of the client by the counselor, the counselor's evaluation of the clients problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors that may inhibit treatment, and the counselor's evaluation of the clients attitude toward treatment and the counselor's impressions/conclusions regarding the client in client records #1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
The Director of Clinical Services and the Director of Social Services will co-facilitate a training with all pertinent staff on 03/11/2009. This training will educate the staff on the importance of completing the psychosocial evaluation from the clinicians perspective. The clinician will be able to gather the needed information from the patients self-assessment and form an evaluation from their own perspective. The Director of Social Services will audit 20 charts weekly to ensure that the clinicians are completing an evaluation and not an assessment. |