INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 7, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, PA Treatment & Healing 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.
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Plan of Correction
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to complete medical histories before the psychosocial evaluation was completed.
The findings include:
Five outpatient client records were reviewed on October 7, 2011. Per facility policy, medical histories are to be completed before the psychosocial evaluation. Medical histories were required in five client records. The facility failed to complete medical histories before the facility documented a psychosocial evaluation in client record #3.
Client # 3 was admitted on June 23, 2011. The medical history was due within fifteen days of intake. The client's medical history was documented on 08-04-11. The psychosocial evaluation was dated 07-07-11. The completion of the medical history occurred twenty-eight days after the psychosocial evaluation was completed on July 07, 2011.
Client Record # 5 was admitted on 03-08-2010. The medical history was signed on 03-08-2010. The psychosocial evaluation was completed on 08-27-2010. The facility failed to complete the medical history prior to the completion of the psychosocial evaluation.
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Plan of Correction
The clinical staff person failed to complete medical history before the psychosocial evaluation was complete. The clinical staff person will make every effort to complete the medical history according to the agency policy. This will be accomplished through scheduling the client for more sessions initially, scheduling longer initial sessions and/or assigning the client homework to aid in the completion of the medical history within the time line as outlined in agency policy. This standard is in compliance immediately. The Facility Director/Clinical staff person will ensure ongoing compliance with this standard through ongoing supervision/training, routine quality checks of files and review of the agency OP D&A Manual. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to complete drug and alcohol histories in accordance with their policy in one of five client records.
The findings include:
Five outpatient client records were reviewed on October 07, 2011. Per facility policy, drug and alcohol histories are to be completed by the fourth treatment session or within fifteen days following intake. Drug and alcohol histories were required in five client records.
Client record #3 was admitted on 06-23-2011. The facility failed to complete drug and alcohol histories before the psychosocial evaluation was completed on 07-07-2011. The drug and alcohol histories had a completion date of 08-04-2011. The information needed to complete an evaluation was not finished by the fourth session or 15 th day after intake as per facility policy. The evaluation was completed before the counselor documented the information needed to complete the evaluation.
A discussion was conducted with the facility director who did not dispute the findings.
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Plan of Correction
The clinical staff person failed to complete the drug and alcohol history before the psychosocial evaluation was complete. The clinical staff person will make every effort to complete the drug and alcohol history within the agency policy. This will be accomplished through scheduling the client for more sessions initially, scheduling longer sessions and/or assigning the client homework to aid in the completion of the drug and alcohol history within the time line as outlined in agency policy. This standard is in compliance immediately. The Facility Director/Clinical staff person will ensure ongoing compliance with this standard through ongoing supervision/training, routine quality checks of files and review of the agency OP D&A Manual. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a personal history before the completion of a psychosocial evaluation in one of five client records.
The findings include:
Five records were reviewed October 7, 2011.
Record #3 was admitted on 06-23-2011. The Psychosocial Evaluation was completed on 07-07-2011. The personal history was completed on 08-04-2011. The facility failed to comply with facility policy to complete the personal history by the fifteenth day following intake or the by the fourth session.
This was discussed with the Facility Director who did not dispute the findings.
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Plan of Correction
The clinical staff person failed to complete the personal history before the psychosocial evaluation was complete. The clinical staff person will make every effort to complete the personal history within the agency policy. This will be accomplished through scheduling the client for more sessions initially, scheduling longer sessions and/or assigning the client homework to aid in the completion of the personal history within the time line as outlined in agency policy. This standard is in compliance immediately. The Facility Director/Clinical staff person will ensure ongoing compliance with this standard through ongoing supervision/training, routine quality checks of files and review of the agency OP D&A Manual. |