INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensure inspection that was conducted on June 1, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Gaudenzia Inc. Winner Co-Occurring Women and Children Program 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 supervisory review:
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Plan of Correction
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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
During a supervisory review of your licensing packet, the reviewer determined that the facility failed to document a psychosocial evaluation in one of four records.
The findings include:
On June 1, 2011, four client records requiring psychosocial evaluations were reviewed, specifically records # 1, 2, 3 and 4. The facility did not document a psychosocial evaluation upon completion of the psychosocial history, in client record # 2.
The facility ' s policy titled " Psychosocial Assessment " states:
Upon completion of the psychosocial histories, the Counselor will write a narrative psychosocial assessment prior to the next scheduled individual counseling session.
In client record # 2, the psychosocial evaluation was completed prior to the completion of the client history. In client record # 2, the client history was dated 4/14/11, but the psychosocial evaluation was dated 4/13/11.
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Plan of Correction
Supervisor will review clinical documentation for appropriate dates and signatures. Director will review treatment plans on a quarterly basis for compliance. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
During a supervisory review of your licensing packet, the reviewer determined that the facility failed to document an individual treatment and rehabilitation plan in one of four records.
The findings include:
On June 1, 2011, four client records requiring treatment and rehabilitation plans were reviewed, specifically records # 1, 2, 3 and 4. The facility did not document an individual treatment and rehabilitation plan based on information collected in the patient history in client record # 3.
The facility ' s policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN " States:
An individualized treatment and rehabilitation plan will be developed with each client after the completion of the client's psycho-social evaluation. The counselor will create, with the client, a proposed treatment plan, based on information collected in patient histories, the bio-psycho-social and assessment and the clients [sic] problem list. The plan will be discussed with the client and changes made upon client request as appropriate.
In client record # 3, the treatment and rehabilitation plan was completed prior to the completion of the client history. In client record #3, the client history was dated 4/4/11, but the individual treatment and rehabilitation plan was dated 4/2/11.
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Plan of Correction
Supervisor reviews treatment plans monthly for signature and will insure correct procedure for treatment planning.
Director will complete review of clinical documentation quarterly to insure compliance. |