INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24 and May 25, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Crossroads Counseling, 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 June 24, 2010.
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Plan of Correction
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705.21 (2) LICENSURE General req. for nonresidential facilities.
705.21. General requirements for nonresidential facilities.
The nonresidential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
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Observations
Based on the review of administrative documents and a physical plant tour the facility failed to have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.The findings include:The administrative policy and procedure manual was reviewed on May 24, 2010. The physical plant was toured on May 24, 2010 at approximately 1:00 p.m. It was observed that the facility did not have a certificate of occupancy from the Department of Labor and Industry or its local equivalent. An interview with the project director confirmed that they did not have an occupancy permit in their possession.
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Plan of Correction
Crossroads Counseling, Inc. just took over this facility 6 weeks prior to this inspection. A copy of the Labor and Industry certificate was requested from the landlord as well as the prior owners, however they failed to provide us with a copy prior to the inspection. A copy was finally obtained and provided to Drug and Alcohol Licensing the day after our onsite inspection so this matter has been resolved. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the 2009 annual report during the onsite licensing inspection, the facility failed to document a financial statement of income and expenses in the body of the report.The findings include:The annual report was reviewed during the licensing inspection on May 24, 2010. The facility failed to include a financial statement of income and expenses in the annual report.
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Plan of Correction
Director provided a corrected financial statement during the onsite inspection. This issue should now be satisfied. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative policies and procedures and an interview with the project / facility director, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24 hour emergency psychiatric and medical coverage.The findings include:The administrative policies and procedures were reviewed on May 24, 2010. The facility was failed to provide a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric and medical coverage, as required. An interview with the project Director on May 24, 2010 at 10:30 A.M. confirmed that a written agreement with a local hospital was not in place.
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Plan of Correction
Crossroads Counseling, Inc. just took over this facility 6 weeks prior to this inspection. Referral agreements with local treatment providers and hospitals were sent out but have not all been returned yet. The executive director will follow up on these documents and continue to attempt to obtain a written agreement with a licensed hospital in the area. In the meantime, we do have a signed agreement with a hospital in Williamsport, a contract with a local agency in State College to handle after hours emergency calls, and our Medical Director does have admitting privileges at a State College area hospital. |
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 client records reviewed, the facility failed to include the client's signature, verifying that the treatment plan was developed with the client in six of eight client records. The findings include:Twelve client records were reviewed on May 25, 2010. Eight client records required an individual treatment and rehabilitation plan that was to be developed with the client. Six of eight records failed to obtain client signatures, verifying that the treatment plan was developed with the client, specifically client records # 6, 9, 10,11, and 12. Also, the facility failed to have client record # 3 sign the treatment plan update.
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Plan of Correction
It is the policy of Crossroads Counseling, Inc. to involve clients in the treatment planning process and have them sign their treatment plans thereby confirming their involvement in this process. Since we took over this facility on April 1st, the executive director and the clinical supervisor have been training the staff on our new paperwork, forms, and policies weekly through supervision, staff meetings, and chart audits. Clinical staff were notified of this citation on May 26, 2010 by the clinical supervisor and reminded of the importance of involving clients in the process and obtaining their signatures to document it. Since that time, the issue has been reviewed regularly in clinical staff meetings and the on-site clinical supervisor has been reviewing charts weekly to assure compliance. |
709.93(b) LICENSURE Client records
709.93. Client records.
(b) The project shall develop and maintain client records on standardized project client record forms.
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Observations
Based on a review of client records, the facility failed to meet the requirement for treatment plan updates in 1 of 2 applicable records.The findings include:Twelve client records were reviewed on May 24, 2010. Treatment and rehabilitation plan updates were required in two records. The facility failed to document a treatment plan update in client record # 7. The treatment update for client record #7 was due on May,18, 2010.
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Plan of Correction
It is the policy of Crossroads Counseling, Inc to update treatment plans at least every 60 days. Since we took over this facility on April 1st, the executive director and the clinical supervisor have been training the staff on our new paperwork, forms, and policies weekly through supervision, staff meetings, and chart audits. Clinical staff were notified of this citation on May 26, 2010 by the clinical supervisor and reminded of the requirement to update outpatient treatment plans at least every 60 days. Since that time, the issue has been reviewed regularly in clinical staff meetings and the on-site clinical supervisor has been reviewing charts weekly to assure compliance. |