INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17 -18, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ellen O'Brien Gaiser Addiction Center 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 14, 2007.
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Plan of Correction
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709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on client record reviews on 10-17-07 and 10-18-07, the facility failed to provide a clinical assessment of the information presented in the individual sessions and how it pertains to the clients' treatment. This was found in three of six client records. Refer to client records # 2, 3 and 5.
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Plan of Correction
On 10/23/07 the Clinical Director conducted a formal clinical training on the correct manner in which to complete the clinical assessment of the information presented in the individual sessions and how it pertains to the clients' treatment. Going forward the clinical director regularly review the clinicains' assessments for accurate clinical assessments going forward. |