This report is a result of an on-site licensure renewal inspection conducted on October 1, 2007 through October 3, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Progressive Medical Specialists, Inc. 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 5, 2007.
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Plan of Correction
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Observations
Based on review of the client records it was determined that the facility failed to document goals on individualized treatment plans that included measurable criteria. Documentation reviewed in client records # 1, 2, 3, 4, 5, 6 and 7 failed to include steps to tell the client how to complete the short term goals.
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Plan of Correction
We believe that since many of our staff are newer to the field treatment plan skills/documentation are not well developed.
We had a staff-training plan we completed last year to assist with treatment plan writing. We do believe that the staff have made improvement but need to work on the "how" piece of the treatment plans.
Director and Clinical supervisor(s) have reviewed the skill levels of each staff member using the "Addiction Counseling Competencies" Technical Assistance Publications (TAPs) number 21 developed by SAMSHA/CSAT; identified additional areas of training for each staff member especially in assessment and treatment plan writing.
We have created a "special training plan" for each staff member that will be added to his or her current training plan focusing of treatment planning and documentation skills.
We plan to assist with the development of staff treatment plan skills/ documentation in the following manner:
1. Clinical supervisors and director will complete a 4-week on line course conducted by IRETA, titled, "treatment planning M.A.T.R.S". This class starts in January and will end in February. We hope that this will assist the supervisors in training staff members with developing treatment plan goals. We are looking for other
courses/trainings that can be taken to improve treatment-planning skills. Staff members will be sent to any local trainings or/and on line trainings that address goal planning/development.
2. Treatment plans are signed by the clinical supervisors, as a result, they will return plans to staff members if the plans are not detailed, specific and well defined with how to steps.
The supervisors have been instructed by director to not sign any treatment plan that does not meet guidelines.
3. Director has put together an in-service in goal planning that includes exercises for the staff to complete. This should be able to be completed in two one hour training sessions and will be completed by November 30, 2007. The director will document the training and staff assessments of the training.
4. We will use our current monthly training updates and individual training plans to monitor progress of each staff member.
We will file all information gathered in each member's personnel chart.
We plan to insert specific trainings in our 2008 calendar that will address assessment skills and treatment planning.
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