INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 4, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, New Directions Treatment Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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
Based on a review of the client record on November 4, 2021, the facility failed to ensure that the treatment plan was updated every 60 days. The first treatment plan update was documented on 2/3/2021 and the next one was not documented until 5/24/2021. The next treatment plan was not updated until 8/13/21. The findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
On November 16, 2021, during a group supervision meeting with the counselors, the Program Director reviewed the state guidelines and regulations pertaining to the timely completion of treatment plans. Counselors were instructed to create spreadsheets as a way to track the due date for treatment plans for all of the clients on their caseloads. The Program Director informed the counselors that the spreadsheets must be updated at the end of each week to ensure that treatment plans are being reviewed and updated every 60 days. On November 16, 2021, during an individual meeting with the counselor overseeing client #1, the Program Director reviewed the treatment plan deficiency regarding the treatment plan that was due on 4/27/2021 but not completed until 5/24/2021; in addition, the Program Director spoke to the counselor about the treatment plan that was due on 7/27/2021, but was not completed until 8/13/2021. To ensure ongoing compliance, the Program Director will require all of the counselors to submit their treatment plan spreadsheets once a week in order to review the timely completion of all documentation in clients' charts.
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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 on a review of the client ' s record on November 4, 2021, the facility failed to provided counseling per the client ' s treatment plans.Comprehensive treatment plan dated 12/9/2020 - Individual sessions 1 per month. There was no documentation of a January 2021 session.Treatment plan update dated 2/3/2021 - Individual or Group sessions every month. There was no documentation of an individual or group session during the months of March and April 2021.Treatment plan update dated 5/24/2021 - Individual or Group sessions every month. There was no documentation of an individual or group session during the months of June and July 2021.Treatment plan update dated 9/27/2021 - Individual once a month. There was no documentation of an individual for the month of October 2021. The findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
On November 16, 2021, during a group supervision meeting with the counselors, the Program Director reviewed treatment and rehabilitation services, noting that counseling services must be provided as outlined and specified in individual treatment plans. During individual supervision, the Program Director met with the counselor overseeing the client whose treatment plans indicated that counseling would occur once per month, and a spreadsheet was created indicating due dates for counseling services. To ensure ongoing compliance with state regulations, the Program Director will require all counselors to track weekly, monthly, and bi-monthly counseling sessions on a spreadsheet which will be monitored and reviewed at least every other week. In addition to a spreadsheet, the Program Director will review client records and caseloads during individual supervision to ensure that counseling sessions are being executed as outlined and specified on treatment plans.
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of the client ' s record on November 4, 2021, the facility failed to document services offered to the client on the following dates:12/9/20 - Individual2/3/21 - Individual3/2/21 - Met with client4/12/21 - Met with client The findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
On November 23, 2021, the Program Director spoke with the counselors during group supervision and reviewed the protocol for recording counseling sessions on a Record of Service document. The counselors were reminded that each counseling session must include a Record of Service to correspond with the documented counseling session, and the Record of Service must include the following items: date of service, time and duration of counseling session, type of service (individual or group therapy), outcome (kept/no show/canceled), provider signature, and client signature. In addition to facilitating a group supervision session on 11/16/2021, the Program Director met with the counselor overseeing the client whose record of service logs were not documented for the following counseling sessions: 12/9/2020, 2/3/2021, 3/2/2021, and 4/12/2021. To ensure ongoing compliance with state regulations, the Program Director will review client records and charts to make sure that the Record of Service is recorded properly to correspond with each counseling session. Furthermore, each counselor will be required to keep a clipboard in their office with designated record of service logs to correspond with daily scheduled counseling appointments. |