INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 14, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, LaRocco 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:
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from January 2024 -December 2024, the facility failed to prepare alternative exit routes to be used during fire drills. All fire drill logs noted "front" or "front entry" as the exit route utilized.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility will ensure not only that alternate exits are used during routine fire drills, but will also ensure that it is documented in the fire drill log as to what exit route was used per drill. Project Director will routinely monitor this process to ensure that it is being done as listed above. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on review of the facility's policy and procedure manual and staff interviews, the facility failed to ensure the Project Director shall prepare, annually update and sign a written manual delineating project policies and procedures.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director has created a sign off form for the annual update and review of policy and procedures to be incorporated immediately. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to purpose of disclosure. This was observed in three out of seven records reviewed.
Client #1 was admitted on October 17, 2024, and was still active at the time of the inspection. A release of information form, for an emergency contact, was signed and dated on January 28, 2025; however, it did not document the purpose of the disclosure. Additionally, a release of information form, for a psychologist, was signed and dated October 29, 2024; however, it did not document the purpose of the disclosure.
Client #2 was admitted on November 27, 2024, and was still active at the time of the inspection. A release of information form, for a treatment provider, was signed and dated on January 9, 2025; however, it did not document the purpose of the disclosure.
Client #7 was admitted on October 25, 2024, and was discharged on December 20, 2024. A release of information form, for a prison, was signed and dated on October 25, 2024; however, it did not document the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
There will be ongoing staff trainings in the proper way to fully complete a confidential release of information. In addition, this will be continuously audited and supervised by supervisory staff at LaRocco Counseling. |
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.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of six applicable records reviewed.
Client #2 was admitted on November 27, 2024, and was still active at the time of the inspection. The treatment plan dated December 12, 2025, indicated two individuals therapy sessions per month. An individual session was documented on Janaury 9, 2025, there was no documentation to verify that a second individual session has occurred during the month of January.
Client #3 was admitted on December 16, 2024, and was still active at the time of the inspection. The treatment plan dated December 23, 2024, indicated one individual therapy sessions per week. There was no documentation to verify an individual session occurred for the weeks of January 26-February 1, 2025, and February 2-February 8, 2025.
Client #5 was admitted on May 1, 2024, and was discharged on November 13, 2024, The treatment plan dated May 8, 2024, indicated one individual therapy session per week. There was no documentation to verify individual sessions occurred for the weeks of September 8-September 14, 2024, October 13-October 19, 2024, October 20-October 26, 2024, and November 3-November 9, 2024.
Client #6 was admitted on April 9, 2024, and was discharged on January 23, 2025. The treatment plan dated April 23, 2024, indicated one individual therapy session per week. There was no documentation to verify that the individual sessions occurred for the weeks of November 24-November 30, 2024, December 1-December 7, 2024, December 22-December 28, 2024, and January 12-January 18, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On going training will be provided in the area of making sure that contact records are up to date and accurate to corelate with the identified frequency of sessions established in treatment planning; furthermore, if there are changes in the frequency of treatment episodes, this will be updated in the treatment plan. This will be audited and supervised routinely by LaRocco Counseling supervisory staff. |