INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Treatment Centers - Detox Unit 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 January 8, 2009..
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Plan of Correction
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of fire extinguishers within seven days of the date of employment in one of four personnel records reviewed.
The findings include:
Four personnel records were reviewed on December 10, 2008 through December 11, 2008. Fire extinguisher training was to be completed within seven days of the date of employment in four personnel records. Fire extinguisher training was completed fifty-one days after the date of employment in personnel record #3.
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Plan of Correction
The Caron new hire checklist (which contains review of fire extinguishers) is given to the hiring manager and they are told to have it back to HR within three days of hire. The HR Specialist will check to make sure that it is received back from the manager on time, and that time frames for fire extinguisher training was completed within the first week of training. Managers will be reminded to complete this if the form is not returned within the 1st 3days of hire so that there is still time left to provide the training. Compliance to this will occur effective Jan. 12, 2008.
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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 document a complete psychosocial evaluation in two of four client records reviewed.
The findings include:
Six client records were reviewed on December 16, 2008. Psychosocial evaluations were required in four client records. The facility did not document evaluative information regarding the client's needs, strengths, support systems and preferred coping mechanisms in client records #5 and 6. Client needs, strengths, support systems and coping mechanisms in client records #5 and 6 were historical/client reported rather than evaluative.
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Plan of Correction
The facility psychologist will complete an "Evaluation/Formulation" section at the end of the Integrated Psychological Evaluation and just prior to the recommendations section.
The purpose of the "Evaluation/Formulation" section is to integrate and interpret the patient's history and mental status in terms of mental health symptoms, mental health diagnosis, psychosocial background and addiction issues, all of which will serve as the basis for recommendations to be included in the patient's treatment plan.
The "Evaluation/Formulation" section will include the psychologist's clinical interpretive analysis of the patient's strengths, needs, support systems, preferred coping mechanisms, negative factors that may inhibit treatment, and patient attitudes that would have either facilitate or inhibit patient's engagement in the treatment process.
The language of the "Evaluation/Formulation" section will reflect the psychologists's interpretations and clinical impressions of the patient's clinical material.
An outline that reflects the above corrections will be incorporated into the "Evaluation/Formulation" section of the evaluation form to insure that psychologists are consistently addressing the same evaluative issues for each patient evaluated in the facility.
Training to assist psychologists in making interpretative clinical impressions in the "Evaluation/Formulation" Section will begin in January 5, 2009.
Person Responsible:
Lead Supervising Psychologist, Adolescent and Young Adult Services
Lead Supervising Psychologist, Adult Services
Person Responsible overall monitoring: Director of Psychological Services
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