INITIAL COMMENTS
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This report is a result of a licensure renewal inspection. The client record review was conducted January 16, 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 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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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on two of six applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days.
Client # 1 was admitted on May 4, 2023, and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on September 29, 2023. A treatment and rehabilitation plan update was due no later than November 29, 2023; however it was not documented until December 5, 2023.
Client # 5 was admitted on April 19, 2023, and was discharged July 20, 2023. A treatment and rehabilitation plan was developed on April 19, 2023. A treatment and rehabilitation plan update was due no later than June 19, 2023; however one was initiated on July 6, 2023 but was not completed.
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 the treatment and rehabilitation plan must be updated at least every sixty days. Re-education was provided on February 6, 2024. Office administration will ensure ongoing compliance by tracking completion of treatment plans and updates. |
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 complete client record on an individual which includes information relative to the client's involvement with the project including follow-up information in two out of three applicable records.
Client # 5 was admitted on April 19, 2023, and was discharged on July 20, 2023. The was no follow-up information documented in the client record.
Client # 6 was admitted on June 7, 2023, and was discharged on January 2, 2024. The was no follow-up information 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 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. |