INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 11, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Bucks County Counseling 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:
|
Plan of Correction
|
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
The facility failed to assure that clients received the required counseling services according to the individual's comprehensive treatment plan in three of seven client records reviewed.
Client #4 was admitted on January 28, 2019 and was discharged on July 24, 2019. The comprehensive treatment plan, dated January 29, 2019, indicated the client was to receive three group therapy session per week (twelve group sessions per month). The chart's record of service and progress notes indicated that the client had received three sessions during February 2019, five sessions during March 2019, three sessions during April 2019, four sessions during May of 2019 and three sessions during June 2019.
Client #6 was admitted on July 17, 2018 and was discharged on May 23, 2019. The comprehensive treatment plan, dated July 17, 2018, indicated the client was to receive three group therapy session per week (twelve group sessions per month). The chart's record of service and progress notes indicated that the client had received five session during August 2018, four sessions during September 2018, one session during October 2018 and four sessions during November 2018. Additionally, the updated treatment plan, dated February 18, 2019, indicated that the client was to receive one group therapy session and one individual therapy session per week (four individual sessions and four group sessions per month). The chart's record of service and progress notes indicated that the client had received three group sessions and two individual sessions during March 2019 and April 2019.
Client #7 was admitted on April 25, 2018 and was discharged on November 11, 2018. The comprehensive treatment plan, dated April 25, 2018, indicated the client was to receive three group therapy session per week (twelve group sessions per month). The chart's record of service and progress notes indicated that the client had received four sessions during May 2018, two sessions during June 2018, zero sessions during July 2018, five sessions during August 2018, three sessions during September 2018 and five sessions during October 2018.
These findings were reviewed with facility staff during the licensing inspection
|
Plan of Correction
Upon examination, it was discovered that this was an issue with the template used to create the treatment plan, which defaulted to 3 sessions a week. Project director will eliminate the wording on the template, which will force the creator of the plan to insert the appropriate verbiage. Project director will sign off on all treatment plans. |
709.93(a) 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:
|
Observations
The facility failed to maintain a complete client record on individuals, which is to include progress notes and case consultation notes, in three of seven client records reviewed.
Client #2 was admitted on December 14, 2018 and was still active at the time of the inspection. There were no documented progress notes from group counseling sessions on July 10, 2019 and July 24, 2019; however, there were entries on the client's record of service for those dates.
Client # 3 was admitted on March 7, 2019 and was still active at the time of the inspection. Per the facility's policy, case consultations are to be done at least every three months; however, there was no case consultation notes documented in the client record at the time of the inspection.
Client # 5 was admitted on May 25, 2018 and was discharged on October 18, 2018. Per the facility's policy, case consultations are to be done at least every three months; however, there was no case consultation notes documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Project director will assume responsibility for examining each active file weekly to confirm that progress note is present for each encounter.
Project director will add to check list for initial file creation an item that requires the case consultation to be entered into project calendar that will remind director of the need for case consultation. Project director will follow up with appropriate counselor to insure case consult is completed and placed in file. |