INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 5, 2008 through May 6, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Libertae Family House Libertae, 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 June 9, 2008.
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Plan of Correction
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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 a complete psychosocial evaluation in four of six records reviewed, #2, 3, 5 and 6. Psychosocial evaluations did not include a clinical assessment of the client's assets/strengths, support systems, coping mechanism and negative factors that may inhibit treatment.
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Plan of Correction
#1759-
The Clinical Director will conduct an instruction around clinical assessment in the Biopsychosocial during the monthly therapist meeting with all the therapists and the counselor assistant. 6/08
The clinical Director will monitor the Biopsychosocial clinical assessment portion during individual supervision as well as during chart reviews. 6/08 |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a review of the client records, the facility failed to document follow-up information in two of three records reviewed, #4 and 6.
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Plan of Correction
#1813
The Clinical Director plans to speak with the Licensing Specialist regarding this deficiency as it was stated to relate to a 30 day follow up. 5/08
Clinical Director will monitor 7 day follow up information during the monthly therapist meeting and in supervision with the therapists. 5/08
The Clinical Director will conduct an aftercare training and requirement review during the montly staff meetings. 6/08
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