INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 19, 2010 through January 21, 2010 licensure renewal inspection. The follow-up inspection was conducted on August 30, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Roxbury 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 September 21, 2010.
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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 a review of client records, the facility failed to document all required components of a psychosocial evaluations in two of four short-term detoxification client records.
The findings include:
Ten records were reviewed on August 30, 2010. Psychosocial evaluations were required in ten records reviewed.
Client record #2 failed to document the client's support systems, coping mechanisms and negative factors that might inhibit treatment.
Client records #3 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and client attitude toward treatment.
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Plan of Correction
Director of Social Work and Director of Clinical Services will conduct trainings with all Clinical and Social Work staff on psycho-social interviewing and documentation. These trainings will be complete by 29 October 2010. The trainings will emphasize proper documentation of assets / strengths, support systems, coping mechanisms, and negative factors that might inhibit treatment from the staff's perspective. Director of Social Work and Director of Clinical Services will audit medical records for compliance. |
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 client records, the facility failed to document all required components of the psychosocial evaluations in two of two outpatient client records.
The finding includes:
Ten records were reviewed on August 30, 2010. Psychosocial evaluations were required in ten records reviewed.
Client record #1 failed to document the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record #2 failed to document the client's assets/strengths, support systems, coping mechanisms and client attitude toward treatment.
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Plan of Correction
Director of Outpatient Services will conduct a training with all Clinical staff on psycho-social interviewing and documentation. The training will be complete by 29 October 2010. The training will emphasize proper documentation of assets / strengths, support systems, coping mechanisms, attitude toward treatment and negative factors that might inhibit treatment from the staff's perspective. Director of Outpatient Services will audit medical records for compliance. Deficiencies will be addressed through supervision and additional training if necessary. |