INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29, 2008 through September 30, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alternative Counseling Associates, 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 October 28, 2008.
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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
Based on a review of six client records on September 29, 2008 through September 30, 2008, the facility failed to document a psychosocial evaluation with the counselor's evaluation of the client's strengths/assets, coping mechanisms, and negative factors that might affect treatment in six of six client records reviewed.
Findings:
The psychosocial evaluations consisted of one word answers without any clinical evaluation regarding the client's strengths/assets, coping mechanisms, and negative factors that might affect treatment in six of six client records reviewed, specifically client records #1, 2, 3, 4, 5 and 6.
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Plan of Correction
We receive a biopsychosocial from the referring facility, which includes strengths weaknesses, coping skills, etc. We also complete our own biopsychosocial with the same expectations. Both documents are maintained in the file, therefore they are in essence "incorporated as one by reference".
Additional corrections/additions will be made to include more positive and negative qualities and other indicators that might hamper treatment.
The Director will monitor the biopsychosocials. Deficiency was the responsibility of the Director. |
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 a review of six client records on September 29, 2008 through September 30, 2008, the facility failed to document group progress notes to include an individualized assessment and plan relative to each individual client participating in the group.
Findings:
The facility did not document an assessment of and a plan for each individual client relative to their response or participation in the group session in six of six client records reviewed, #1, 2, 3 4, 5 and 6.
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Plan of Correction
All group progress notes will include subjective evaluations and assessment of group progress and response thereto. The Director will monitor group progress notes. The deficiency was the responsibility of the Director. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of CPR and first aid cards, as well as staff schedules and staff interview on September 29, 2008, the facility failed to ensure that at least one staff person trained in CPR and first aid was onsite during the hours of operation.
Findings:
According to the staff schedules and staff interview, three staff who work the weekend shifts each Saturday and Sunday were not certified in CPR or first aid. There was no staff person onsite with CPR and first aid certification on the following dates: September 6, 2008; September 7, 2008; September 13, 2008; September 14, 2008; September 20, 2008; September 21, 2008; September 27, 2008; and September 28, 2008.
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Plan of Correction
All necessary trainings are complete. Both staff in question are no longer employed. All future employees will have appropriate trainings. The Director will monitor staff trainings. Deficiency was the responsibility of the Director. |