INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11-13, 2008, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Roxbury Treatment 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 March 21, 2008.
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Plan of Correction
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709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based upon a review of client records during the licensing inspection on January 13, 2008, the facility failed to provide a complete family history in two of four client records reviewed, specifically client records #1 and 2; and failed to include information regarding childhood history and/or any major or significant life events.
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Plan of Correction
Clinical Director will implement training on 3/14/08 with pertinent staff on psycho-social interviewing and documentation; specifically focusing on gathering detailed answers that will give the reader a better understanding of the patient's personal history to include family, childhood, and any major or significant life events. Clinical Director will audit records weekly for compliance. |
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 upon a review of client records during the licensing inspection on January 13, 2008, the facility failed to provide a clinical assessment of the client's assets and strengths in two of four client records reviewed, specifically client records #1 and 2; and failed to identify the client's coping mechanisms in two of three client records reviewed, specifically client records #1 and 5.
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Plan of Correction
Clinical Director will facilitate training on 3/14/08 with pertinent staff on psycho-social interviewing and documentation; focusing on proper documentation of each client's assets and strengths and how to identify the client's coping mechanisms from the staff's perspective. Clinical Director will audit records weekly for compliance. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based upon a review of client records during the licensing inspection on January 13, 2008, the facility failed to provide a complete family history in 4 of 5 client records reviewed, specifically client record #1 through 4; and failed to include information regarding childhood history and/or any major or significant life events.
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Plan of Correction
Clinical Director will facilitate training on 3/14/08 with pertinent staff on psycho-social interviewing and documentation; specifically focusing on gathering detailed answers that will give the reader a better understanding of the patient's personal history to include family, childhood, and any major or significant life events. Clinical Director will audit records weekly 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 upon a review of client records during the licensing inspection on January 13, 2008, the facility failed to provide a clinical assessment of the client's assets and strengths in two of five client records reviewed, #1 and 2; and failed to identify the client's coping mechanisms in two of five client records reviewed, #1 and 4.
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Plan of Correction
Clinical Director will facilitate a training on 3/14/08 with pertinent staff on psycho-social interviewing and documentation; focusing on proper documentation of each client's assets and strengths and how to identify the client's coping mechanisms from the staff's perspective. Clinical Director will audit records weekly for compliance. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based upon a review of client records on January 13, 2008, the facility failed to develop treatment plans and provide services in accordance with the governing body's philosophy ( "Disease Concept" ), purpose and goal (abstinence). Treatment plans in 4 of 4 client records reviewed were developed with reduction of use or 'controlled use' being the goal rather than abstinence.
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Plan of Correction
Roxbury Treatment Center has always held the philosophy that abstinence is the only acceptable means to recovery from the disease of addiction; and this remains our core philosophy when developing treatment care plans for clients diagnosed with substance dependence. Increasingly, however, in the outpatient setting we are being asked to provide treatment to clients who meet criteria for substance abuse, and who may not have progressed to the point of a diagnosis of chemical dependency.
The 4 client records referenced in Item 1885 are younger clients in the college setting diagnosed with Alcohol Abuse and currently experiencing minimal lifestyle impacts of their alcohol use. Recognizing the need to individualize our treatment approach, our aim is to not treat clients generically. For these individuals treatment will involve a process of evaluating impacts, altering use patterns, examining choices, and examining faulty beliefs; all for the purpose of determining a more accurate clinical impression of the individual's use. This is not strictly a didactic, educational format as it involves client self-examination and behavior change facilitated by a trained clinician.
That said, in taking a closer look at this issue, it is agreed that treatment plans and treatment expectations will be modified to include the goal of abstinence during the episode of treatment and that treatment will entail a discussion of each client's potential difficulties in attaining the stated goal. Failure to achieve the goal of abstinence will not in all instances result in an unsuccessful discharge or transfer of the client if no indicators of substance dependency are present. If at any time during the treatment process an individual shows evidence of having progressed in the stages of dependency, the treatment plan would then be modified, with a referral to a higher level of care or an unsuccessful discharge, if appropriate. Treatment Plan development changes will be implemented beginning March 17, 2008 following a formal training for OP staff by Director of Outpatient Services.
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