INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 14, 2010 through April 15, 2010 licensure renewal inspection. The follow-up inspection was conducted on September 28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Open Door Counseling at Mazzoni Center 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 October 24, 2010.
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Plan of Correction
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709.91(b)(6) LICENSURE Intake and admission
709.91. 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 evaluate psychosocial evaluations in two of three client records reviewed.
The finding includes:
Eight records were reviewed on September 28, 2010; psychosocial evaluations were required in three records reviewed, #3, 7 and 8.
Client records #7 failed to document the client's assets/strengths, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions.
Client records #8 failed to document the client's assets/strengths, support system, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions.
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Plan of Correction
Program Director held meeting with staff to address this deficiency on 10/18/2010. Staff was instructed on how to properly incorporate client's assets/strengths, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment into the case conceptualization/conclusion part of the client evaluation.
Having been trained and now having a better understanding of what is expected, staff will begin immediately incorporating these changes into their documentation.
Clinical supervisor and Program Director will monitor on an on-going basis to ensure compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction
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Plan of Correction
Prior policy had Treatment Plan updates occuring 60 days from the date of intake and used the date of intake as the marker for all subsequent updates. Policy and procedures were corrected to indicate due date for Treatment Plan updates is 60 days following Comprehensive Treatment Plan completion.
Program Director will review change with staff at in-service meeting on 6/14/10. Director and staff will review due date and procedures for completing plans within specified time-frame.
Clinical Supervisor and Program Director will oversee changes are implemented and Program Director will ensure on-going compliance.
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709.93(a)(9) LICENSURE Client records
709.93. 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) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans in three of six discharge records reviewed.
The findings include:
Eight records were reviewed on September 28, 2010; aftercare plans were required in six client records reviewed, #1, 2, 3, 4, 5 and 6.
Client records #1, 3 and 5 did not have documentation of the client's time frames for goals documented in their aftercare plan and the contact person for re-entry to the program was not included on the aftercare form.
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Plan of Correction
Program Director amended Aftercare Plan form to include information about how to re-enter the program post discharge, including contact information.
A meeting was held with staff on 10/18/2010 to review this revision and to instruct staff on the proper procedures for completing Aftercare Plans. Staff was instructed to clearly indicate timeframes for all goals indicated on the Aftercare plans on a consistent basis.
Clinical Supervisor and Program Director will monitor on an on-going basis to ensure compliance with this standard. |