INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 30, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Catholic Charities Counseling and Adoption 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:
|
Plan of Correction
|
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
The facility failed to document case consultations in client records #2, 5, 6 and 7.
Client #2 was admitted on February 19, 2020 and is still an active client. There were no case consultations documented in client record #2.
Client #5 was admitted on February 13, 2020 and discharged on May 28, 2020. There were no case consultations documented in client record #5.
Client #6 was admitted on January 7, 2020 and discharged on May 21, 2020. There was no documentation of case consultation in client record #6.
Client #7 was admitted on March 17, 2020 and discharged on July 21, 2020. There was no documentation of case consultation in client record #7.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Starting Oct 1, 2020 the Program Director will meet weekly with the worker who failed to complete Case Consultations in order to ensure compliance. The missing Case Consultations will be completed by Oct 31, 2020 and all future Case Consultations will be completed in a timely manner. |
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.
|
Observations
The facility failed to document follow up information in client records #6 and #7.
Client #6 was admitted on January 7, 2020 and discharged on May 21, 2020. Per facility policy, follow up contact is made thirty days after discharge. There was no documentation of follow up contact in client record #6.
Client #7 was admitted on March 17, 2020 and discharged on July 21, 2020. Per facility policy, follow up contact is made thirty days after discharge. There was no documentation of follow up contact in client record #7.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Starting October 1, 2020 the Program Director will review weekly all caseload reports and client files to ensure that proper and thorough documentation on client contacts and follow-ups are accurately detailed in the notes / Record of Service. |