This report is a result of an on-site licensure renewal inspection conducted on April 22, 2008 through April 24, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Creative Health 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 May 20, 2008.
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Plan of Correction
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Observations
Based on a review of the facility's annual report and staff interview, the facility failed to include a statement within the annual report disclosing the names of officers, directors and principal shareholders.
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Plan of Correction
By 4/25/08, Facility Director (#2) will include, within the annual report, a statement disclosing the names of the governing body's officers and members. |
Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in nine of nine client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8 and 9. Psychosocial evaluations were missing a clinical assessment of the client's problems/needs in three of nine client records reviewed, #6, 7 and 8. The client's coping mechanisms were missing in three of nine client records reviewed, #1, 5 and 9. Clinical impressions were historical rather than evaluative in nine of nine client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8 and 9.
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Plan of Correction
By 5/2/08 facility director/clinical supervisor (#2) will revise the psychosocial evaluation form to facilitate compliance with the DOH psychosocial evaluation requiremwents and submit revision to project director (#1).
By 5/6/08 facility director/clinical supervisor (#2) will have oriented clinical staff (#3), (#4), (#5), (#6) and (#7) to the DOH psychosocial evaluation standards regarding assessment of client problems/needs, coping mechanisms and evaluative nature of clinical impressions.
By 5/8/08 facility director/clinical supervisor (#2) will have oriented clincal staff (#3-#7) to the revised psychosocial evaluation form and will begin to review each psychosocial evaluation completed by all clinical staff to ensure compliance with the DOH psychosocial evaluation requirements.
By 5/14/08 facility director/clinical supervisor (#2) will provide individual supervision to clinical staff (#5) and review/correct client record #5 re: coping mechanisms and clinical impressions.
By 5/15/08 facility director/clinical supervisor (#2) will provide individual clinical supervision to clinical staff (#4) and review/correct client file #4 and #7 re: assessment of problems/needs and clinical impressions.
By 5/15/08 facility director/clinical supervisor (#2) will provide individual clinical supervision to clinical staff (#7) and review/correct client record #3 and #6 re: clinical impressions and assessment of problem/needs.
By 5/16/08 facility director/clinical supervisor (#2)will provide individual clinical supervision to clinical staff (#3) to review/correct client record #1, #8 and #9 re: coping mechanisms, clinical impressions and assesment of problems and needs.
By 5/19/08 facility director/clinical supervisor (#2) will provide individual clinical supervision to clinical staff # 6 and review/correct client record # 2 re: clinical impressions. |