INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 26, 2007 through June 27, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 20, 2007.
|
Plan of Correction
|
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Psychosocial evaluations were historical rather than evaluative and failed to include clinical impressions regarding the client's problems/needs, assets/strengths, support systems, negative factors that may inhibit treatment, the client's attitude toward treatment and coping mechanisms in four of four client records reviewed, # 1, 2, 3 and 4.
|
Plan of Correction
709.81/Intake and Admission (b) (6)
Clinical Services Manager will educate intake/assessment counselors by
July 31, 2007 on how the evaluation should provide a 'composite picture' of the individual in relationship to the collected historical information in order to identify
possible relationships, conditions and causes leading to the client's current
situations.
|
709.83(a)(9) LICENSURE Client records
709.83. 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:
(9) Progress notes.
|
Observations
Group progress notes did not indicate the client's participation in group and did not provide assessment of the client in four of four client records reviewed, #1, 2, 3 and 4.
|
Plan of Correction
709.83/Client Records (a) (9)
Drug and Alcohol Services Manager will educate clinical staff by July 10, 2007,on the 'assessment' piece of the DAP progress notes to reflect interpretative statements
based upon both new and previous information which should include the counselor's analysis of and conclusions regarding the client's current situation or status.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Psychosocial evaluations were historical rather than evaluative and failed to include clinical impressions regarding the client's problems/needs, assets/strengths, support systems, negative factors that may inhibit treatment, the client's attitude towards treatment and coping mechanisms in eight of eight client records reviewed, # 1, 2, 3, 4, 5, 6, 7 and 8.
|
Plan of Correction
709.91/Intake and Admission (b) (6)
Clinical Services Manager will educate intake/assessment counselors by
July 31, 2007, on how the evaluation should provide a 'composite picture' of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current
situations.
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
The facility failed to provide documentation of TB/STD training within one year of hire date for employee #1..
|
Plan of Correction
704.11/Training requirements(c) (1)
Project Director will complete a minimum of 4 hours of tuberculosis, sexually transmitted diseases by July 18, 2007 in State College, PA..
|
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
The facility failed to provide documentation that employee number 1 received 12 hours of training for the prior training year.
|
Plan of Correction
704.11/Training Requirements (d) (2)
Project Director to complete a minimum of 12 clock hours throughout fiscal year in areas such as; Fiscal policy, Administration, Program planning, Quality assurance, Grantsmanship,Personnel management, Confidentiality, Ethics, Substance abuse trends, Developmental psychology, Interaction of addiction and mental illness, Cultural awareness, Sexual harassment, Relapse prevention, Disease of addiction.
|