INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 19 through 20, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cen-Clear Child Services, 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 13, 2009.
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Plan of Correction
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709.91(b)(6) LICENSURE Intake and admission
709.91. 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 and interviews with the Project and Facility Directors, the facility failed to document the counselor's evaluations on the psychosocial evaluations in 6 of 9 client records.
The findings include:
Nine active client records were reviewed on October 20, 2009. The psychosocial evaluations in 6 client records did not include the counselor's evaluations of the client's problems and needs, assets and strengths, negative factors, the client's preferred coping mechanisms and the counselor's conclusions regarding the client's appearance, behavior and reactions during the intake process.
The psychosocial evaluation in client record # 1 did not address the client's problems and needs and did not include documentation of the counselor's conclusions and impressions. There was no evaluation of the client's support systems and the negative factors that could impact on the recovery effort. The client was admitted on 5/2/09 and the psychosocial evaluation was documented on 5/2/09.
The psychosocial evaluation in client record # 2 did not address the negative factors that could impact on the recovery effort and failed to include the counselor's evaluations of the client's problems and needs, support systems, coping mechanisms and the counselor's conclusions and impressions. The client was admitted on 7/6/09 and the psychosocial evaluation was documented on 7/14/09.
The psychosocial evaluation in client record # 3 did not include the counselor's evaluations of the client's assets and strengths, support systems, coping mechanisms, negative factors that could impact the recovery effort and the client's attitude toward treatment. The client was admitted on 9/16/09 and the psychosocial evaluation was documented on 9/28/09.
The psychosocial evaluation in client record # 5 did not include the counselor's evaluations of the client's assets and strengths, coping mechanisms, and negative factors that could impact the recovery effort. The client was admitted on 8/13/09 and the psychosocial evaluation was documented on 8/20/09.
The psychosocial evaluation in client record # 7 did not include the counselor's evaluations of the client's assets and strengths, support systems, coping mechanisms, negative factors that could impact on the recovery effort and the counselor's conclusions and impressions regarding the client's attitude and ability to participate in the treatment process. The client was admitted on 8/12/09 and the psychosocial evaluation was documented on 8/19/09.
The psychosocial evaluation in client record # 8 did not include the counselor's evaluations on the client's problems and needs, support systems, coping mechanisms, negative factors that could impact on the recovery effort and the counselors conclusions and impressions regarding the client's attitude and ability to participate in the treatment process. The client was admitted on 9/16/09 and the psychosocial evaluation was documented on 9/24/09.
The findings were confirmed during an interview with the project and facility director on October 20, 2009 at 3:45 PM.
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Plan of Correction
CCS developed and incorporated the clients impressions, conclusions as part of the narrative descripter in the psychosocial. All active clients willl have completed updated psychosocials as part of the intake process. The psychosocial and other pertinent documentation will be reviewed by facility director during supervision. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records and interviews with the Project and Facility Directors, the facility failed to ensure that the short and long term goals for treatment were formulated by both staff and client and that the goals were consistent with the conclusions of the psychosocial evaluation in seven of nine client records.
The findings include:
Nine active client records were reviewed on October 20, 2009. The treatment goals and objectives listed in seven of nine client records were not consistent with the conclusions noted in the psychosocial evaluation.
The treatment plan in client record # 1 included short and long term goals and objectives that were not individualized to the specific client as reflected by the conclusions noted in the psychosocial evaluation. The treatment plan was completed on 6/9/09 and the psychosocial evaluation was completed on 5/2/09.
The treatment plan in client record # 2 included short and long term goals and objectives that were not individualized to the specific client as reflected by the conclusions noted in the psychosocial evaluation. The treatment plan was completed on 7/14/09 and the psychosocial evaluation was completed on 7/14/09.
The treatment plan in client record # 3 included short and long term goals and objectives that were not individualized to the specific client as reflected by the conclusions noted in the psychosocial evaluation. The treatment plan was completed on 10/14/09 and the psychosocial evaluation was completed on 9/28/09.
The treatment plan in client record # 4 included short and long term goals and objectives that were not individualized to the specific client as reflected by the conclusions noted in the psychosocial evaluation. The treatment plan was completed on 10/19/09 and the psychosocial evaluation was completed on 8/17/09.
The treatment plan in client record # 6 included short and long term goals and objectives that were not individualized to the specific client as reflected by the conclusions noted in the psychosocial evaluation. The treatment plan was completed on 9/2/09 and the psychosocial evaluation was completed on 8/27/09.
The treatment plan in client record # 7 included short and long term goals and objectives that were not individualized to the specific client as reflected by the conclusions noted in the psychosocial evaluation. The treatment plan was completed on 9/4/09 and the psychosocial evaluation was completed on 8/19/09.
The treatment plan in client record # 8 did not include documentation of short and long term goals and objectives. The treatment plan was completed on 10/8/09 and the psychosocial evaluation was completed on 9/24/09.
This was confirmed through interviews with the Project and Facility Director at 3:45 PM on October 20, 2009.
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Plan of Correction
The clinical impressions and conclusions section of the psychosocial now consists of the treatment impressions and direction as well. These initial impressions will reflect short and long term treatment goals for the individualized treatment plan. Consistent with the psychosocial. These will be reviewed by the facility director or cliinical supervisor. |