INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 21, 2009 through January 22, 2009 licensure renewal inspection. The follow-up inspection was conducted on October 13, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Berks Counseling Center, Inc. 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 November 11,2009.
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Plan of Correction
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records during an unannounced follow-up inspection conducted on October 13, 2009, the facility failed to document a psychosocial evaluation for each client in four of ten client records. The findings include:Sixteen client records were reviewed on October 13, 2009. A psychosocial evaluation was required in ten client records. The facility failed to document a psychosocial evaluation in four of ten client records. There was no psychosocial evaluation documented in client records #1, 2, 6 and 8.
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Plan of Correction
A training to review the policy and procedure of completing a Psychosocial Evaluation (clinical summary) will be held on November 4, 2009. This training will be facilitated by BCC's 2 Clinical Supervisors and Clinical Director. Each individual therapist, designated with a deficiency during the audit, will be addressed during individual supervision with thier direct clinical supervisor regarding the policy and procedure of completing a Psychosocial Evaluation and will review all their cases for additional missing Psychosocial Evaluations.
Clinical supervisors will monitor, via chart reviews, for further Psychosocial Evaluation deficiencies on a monthly basis.
Full compliance will be expected by December 1, 2009. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records and an interview with the Clinical Supervisor,during an unannounced follow-up inspection conducted on October 13, 2009, the facility failed to document follow-up information in six of ten client records reviewed. The findings include:Sixteen client records were reviewed on October 13, 2009. Follow-up information was required in ten client records. The facility failed to document a follow-up in six of ten client records. There was no follow-up information documented in client records #7, 8, 10, 12, 13 and 16. Based on a staff interview with the clinical supervisor, the facility was unaware that follow-up was required to be completed on all clients. The facility was only completing follow-up on clients who successfully completed treatment.
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Plan of Correction
A new system of tracking and completing follow up information has been developed and will be implemented on October 28th following a training on the policy and procedure of completing follow ups, FOR ALL CLIENTS and on the new system, during clinical team group supervision that same day. Clinical Supervisors and Clinical Director will facilitate the training.
Clinical Supervisors will monitor completion of follow ups and adherence to the new system on a weekly basis during weekly individual therapist supervision.
Full compliance will be attained by December 1, 2009. |