INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 16 through 18, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System At Williamsburg 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 April 18, 2009.
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Plan of Correction
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document psychosocial evaluations in two of two client records.
The findings include:
Five detoxification only records were reviewed on March 16 through 17, 2009. Psychosocial evaluations were required in two client records. The facility did not completely document psychosocial evaluations in client records # 1 and 12. Client records # 1 and 12 were missing composite picture, assets/strengths, support systems, coping mechanisms, negative factors, client's attitude towards treatment and the counselor's conclusions and impressions of the client.
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Plan of Correction
Psychosocial Eval:
709.62. Intake and admission. (c) Intake procedures shall include documentation of the following: (6) Psychosocial evaluation.
Intake procedures at Cove Forge for detox- only clients shall include a thorough and complete psychosocial evaluation. Included will be the following:
-client's assets & strengths
-support systems
-coping mechanisms
-negative factors
-client's attitude toward treatment
-client's behavior and reactions during intake
-Impressions and conclusion.
Detox nursing staff will be responsible for completing the psychosocial on detox- only clients. Staff will receive training by the Detox Unit Coordinator at a scheduled staff meeting on April 23, 2009.
Detox staff will complete daily audits on 100% of the detox- only client records times three months.
Responsible Staff:
Detox nurses, and Detox Unit Coordinator
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in one of three client records.
The findings include:
Five detoxification only client records were reviewed on March 16 through 18, 2009. Follow-up information was required in three client records. The facility did not document follow-up information in client record # 14.
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Plan of Correction
709.63. 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: (8) Follow-up information.
There shall be a complete client record on every client at Cove Forge which includes follow-up information.
The case management staff and counselors will be responsible for completing a "Residential Treatment Follow-Up Form" on all detox clients. The follow-up policy and form for documenting follow-up will be reviewed with Counselors and Case Managers after the policy and form are revised by the Performance Improvement Committee and Forms Committee.
Staff will be re-educated on the follow- up policy and the use of the form on April 23, 2009.
Medical Records will do ongoing monitoring for follow-up documentation after clients are discharged.
Responsible Staff:
Performance Improvement Committee, Forms Committee, Detox Unit Coordinator, and Medical Records Coordinator
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709.51(a)(1) LICENSURE Criteria for Admission
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
Based on the review of client records and facility staff verbal confirmation, the facility failed to ensure that clients met the criteria for admission for the inpatient non-hospital - residential treatment and rehabilitation in two of two client records reviewed.
The findings include:
Nineteen client records were reviewed on March 16 through 19, 2009. Partial hospitalization clients attended inpatient therapeutic groups in two of two client records reviewed, # 16 and 17.
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Plan of Correction
Criteria for Admission:
709.51. Intake and admission. (a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to: (1) Criteria for admission.
Clients identified for partial hospitalization treatment will receive partial treatment programming.
Beginning May 15, 2009, all clients identified for partial hospitalization treatment will be assigned to a counselor who will treat them in both individual and group therapy. The client to staff ratio will be 10:1. All partial clients at Cove Forge will attend partial program therapy groups.
Responsible Staff:
Regional Director & Adult Program Director.
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