INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Counseling Services 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 19, 2008.
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Plan of Correction
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709.81(b)(6) LICENSURE Intake and admission
709.81. 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, the facility failed to document a complete psychosocial evaluation in four of four client records reviewed.
The findings include:
Six client records were reviewed on December 15, 2008. Psychosocial evaluations were required in four client records. The facility did not document evaluative information regarding the client's strengths in client records #1, 3 and 4. Client strengths in client records #1, 3 and 4 were historical/client reported rather than evaluative. The facility did not document the client's potential or available support systems in client record #4. The facility did not document the client's preferred coping mechanisms in client records #2 and 4. The facility did not document the client's attitude toward treatment in client record #2.
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Plan of Correction
The Addictions Counselor will complete the Psychosocial evaluation for each patient. The evaluative information will be documented in the Integrated Summary. The evaluative information will include the following: client strengths, potential or current support systems for the client, coping mechanisms (positive or defensive mechanisms), negative factors that may affect treatment and the client's attitude toward treatment. The Addiction Counselor's clinical interpretive analysis will be utilized when completing the Integrated Summary.
An outline that reflects the above corrections will be incorporated into the Integrated Summary template form to insure that the Addictions Counselors are consistently addressing the same evaluative issues for each patient evaluated in the facility.
Training to assist the Addictions Counselors in making interpretative clinical impressions in the Integrated Summary will be completed by January 9, 2009.
Person Responsible:
Team Leader for Caron Counseling Services will conduct monthly chart reviews to insure this procedure is being followed.
Person Responsible for overall monitoring: Director of Outpatient Services - completion date 1/9/09
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document support services on the treatment plan in three of four client records reviewed.
The findings include:
Six client records were reviewed on December 15, 2008. Treatment plans with support services were required in four client records. The facility did not document support services on the treatment plan in client records #2, 3 and 4.
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Plan of Correction
The Addictions Counselor will complete the Treatment Plan with each client. This plan shall include, but not be limited to, written documentation of: the proposed type of support service.
Training to assist the Addictions Counselors to complete treatment plans which includes the proposed type of support service will be completed by January 9, 2009.
Person Responsible:
Team Leader for Caron Counseling Services will conduct monthly chart reviews to insure this procedure is being followed.
Person Responsible for overall monitoring: Director of Outpatient Services
Completion Date: 1/09/09
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