INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 26, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services Carlisle 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(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to ensure that the client signed and dated the treatment plan to show that it was developed with their counselor.
The following includes:
Eight client records were reviewed on February 26, 2013. Per the facility policy, treatment plans will be developed within 30 days of the client's admission date. The client is required to sign and date the treatment plan to identify that it was developed with their participation. Based on the review of client records, the client signed the treatment plan but the date that was written was not documented by the client. There was no record to verify that the client participated in the development of the treatment plan.
Client #1 was admitted on August 30, 2012 and their treatment plan was developed on September 30, 2012. There was no documentation in the client's record of service identifying that the client was in the office on the date documented.
Client #3 was admitted on August 10, 2012 and their treatment plan was developed on September 10, 2012. There was no documentation in the client's record of service identifying that client was in the office on the date documented.
Client #4 was admitted on August 8, 2012 and their treatment plan was developed on September 8, 2012. There was no documentation on the client's record of service identifying that client was in the office on the date documented.
Client #5 was admitted on July 31, 2012 and their treatment plan was developed on August 31, 2012. There was no documentation on the client's record of service identifying that client was in the office on the date documented.
Client #7 was admitted on August 27, 2012 and their treatment plan was developed on September 27, 2012. There was no documentation on the client's record of service identifying that client was in the office on the date documented.
Client #8 was admitted on August 6, 2012 and their treatment plan was developed on September 6, 2012. There was no documentation on the client's record of service identifying that client was in the office on the date documented.
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Plan of Correction
The Clinical Supervisor will meet with all clinical staff during staff meeting and review the procedure for obtaining client signatures on the treatment plan. If a client is seen briefly for a treatment plan review but not for a billable session, the therapist will be instructed to document accordingly in the chart. Therapists will also be instructed to ensure that the client dates his/her own signature. The Vice President of Quality Improvement and Director of Quality Improvement will montior for ongoing compliance via random chart audits. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in two of four client record.
The findings include:
Ten client records were reviewed on February 26, 2013. Per the facility policy, the counselor and client will complete an aftercare plan prior to discharge for successful completions. An aftercare plan was required in four client records. The facility did not document an aftercare plan in client records #6 and 8.
In client record # 6, the client was admitted on October 11, 2012 and was discharged on January 23, 2013. There was no documentation of an aftercare plan.
In client record #8, the client was admitted on August 6, 2012 and was discharged on November 6, 2012. There was no documentation of an aftercare plan.
This was discussed and confirmed with facility staff on February 26, 2013.
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Plan of Correction
The Clinical Supervisor will meet with all clinical staff during staff meeting and review the procedure for completing the aftercare plan with the client prior to discharge for successful completion of treatment. The office administrator will complete a weekly review of discharge charts to ensure completion of the aftercare plans. |