INITIAL COMMENTS
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This report is a result of a licensure renewal inspection. The client record review was conducted January 18, 2024, and a physical plant inspection conducted on January 24, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the annual inspection, Pennsylvania Counseling Services, 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:
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Plan of Correction
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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 have a complete client record on an individual which includes information relative to the client's involvement with the project including an aftercare plan in one of two applicable records.
Client # 5 was admitted on June 7, 2023, and was discharged on November 30, 2023.
There was no aftercare plan documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director of Outpatient Services provided re-education to all clinical and administrative staff that an aftercare plan must be completed for each successfully discharged client. Re-education was provided on February 6, 2024. Office administration will ensure ongoing compliance by tracking completion of aftercare plans when a client is successfully discharged. |
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 a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project including follow-up information in two of three applicable records.
Client # 5 was admitted on June 7, 2023, and was discharged on November 30, 2023.
There was no follow-up information available in the client record.
Client # 6 was admitted on September 12, 2023, and was discharged on December 2, 2023.
There was no follow-up information available in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director of Outpatient Services provided re-education to all clinical and administrative staff that follow-up information must be documented for each discharged client. Re-education was provided on February 6, 2024. Office administration will ensure ongoing compliance by tracking completion of follow-up information when a client is discharged. |