This report is a result of a complaint investigation conducted on April 18, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations against Berks Counseling Center, Inc were unable to be substantiated. However, based on other findings during this investigation, the facility was found out of compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiency was identified during this inspection:
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Plan of Correction
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Observations
Based on an on-site complaint investigation and an interview with the facility director, the facility failed to maintain a data collection and record keeping system that allowed for the efficient retrieval of data.
The findings include:
An on-site complaint investigation was conducted at the facility on April 18, 2016 as well as an interview with the facility director. At approximately at 10:00 am, it was requested that the facility provide a list of active clients. At approximately 11:26 am, the facility provided a list of active client, however, the list was not a complete census. It took until 1:40 pm for the complete active client list to be provided.
This deficiency was reviewed with facility staff during the onsite complaint investigation.
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Plan of Correction
A workbook will be created to include all therapists, with a spreadsheet for each therapist. It will have each therapist's list of active clients and will be sorted by Mental Health and D&A/Co-occurring. This workbook will completed by the Compliance Director and/or Program Assistant by 5/31/16. As therapists get new clients, they will be added to the spreadsheet by the Program Assistant. When clients are being discharged, the Program Assistant will remove them from the spreadsheet. The workbook will be updated on a daily basis or as needed. It will include the total numbers for each program and the total number of clients for each counselor. The Clinical Supervisors will be able to access individual spreadsheets at any given time to view and/or print the daily client census for each therapist. The only persons who will have access to modify the workbook will be the Compliance Director, Program Assistant, and Clinical Supervisors. Counselors will be instructed by Clinical Supervisors to notify the Program Assistant when discharging a client. The instructions and workbook will be in effect by 6/1/16.
We are also exploring ways to create a report that can be generated from our Quic Docs system to get an accurate client census. The current report we can access does not sort by program. It often includes inactive clients because discharges are only processed weekly. There is no estimated completion for the report at this time as we still have to assess the system capabilities.
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