INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 14, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Fountain Springs 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 January 8, 2007.
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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 and staff interview, the facility failed to document a psychosocial evaluation in five of five client records reviewed, #1, 2, 3, 4 and 5. The psychosocial evaluation was missing an overall composite picture of the client, the client's problems/needs, support systems and coping mechanisms. The client's strengths/assets and negative factors that may inhibit treatment were stated in terms of the client's opinion versus a clinical assessment by the counselor.
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Plan of Correction
The psychosocial evaluation will include a composite picture of the client, the client's problems/needs, support systems and coping mechanisms. The evaluation will also contain a clinical assessment of the client's strengths/assets and negative factors inhibiting treatment. The Program Director will provide training to the staff to detail how this is to be addressed and documented in the client file. The Program Director will review all psychosocials to ensure compliance. |
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 a review of client records and staff interview, the facility failed to document follow-up information in five of five records reviewed, #1, 2, 3, 4 and 5. Follow-up information was missing.
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Plan of Correction
Follow-up contacts will be made and documented on every client. A specific form designed to gather and document follow-up information will be maintained in a separate binder. The Program Director will train all detox staff on the follow-up procedure in a meeting scheduled for 1/7/08. The Program Director will review the follow-up contacts to ensure compliance. |