INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23, 24 and 26, 2009 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 March 23 , 2009.
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Plan of Correction
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709.28(c)(2) 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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of the client records during the onsite licensing inspection of February 23-26,2009, the facility failed to document consents to release information which identified the specific information to be released to funding entities and exceeded the amount of information approved by the client for release when releasing client related information in three of seven client records. The findings included:The consents to release information in client records # 3, 4 and 7 identified information to be released under the heading of "billing information" . This descriptor on the consent to release information form did not include the specific pieces of information to be included in the billing information which were to be released. Consent to release information forms in these client records only identified the following pieces of information which would be released by the agency: admission, attendance, diagnosis and billing information. The clients signed these releases as written. Actual information released in client record # 3 included information related to the clients progress in treatment, abstinence and support systems.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all state and federal confidentiality laws. The consent forms in question have been updated to identify the specific information being released. The language that is now being used follows PA Code 255.5 exactly. William Knecht, Director, will perform a staff training on the new forms on 3/24/2009. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of the client records during the onsite licensing inspection conducted on February 25, 2009, the facility failed to document complete personal histories in five of seven client records. The findings include:Family relationships were not described in client records # 1, 2, 3, 4. The educational history in client record # 7 did not document the individual's relationships and extracurricular interests. The employment history did not document a complete record of the individual's dates of employment, details related to performance or reasons for separation in client record # 3. A sexual history was not documented in client record # 2.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with the intake and admission documentation requirements. Clinical supervisors and staff will be re-trained on the proper completion of client histories, with specific emphasis placed on education history, employment history, and sexual history. This training will be performed by the Director, William Knecht on 3/24/2009. Client histories will be reviewed regularly in clinical supervision to assure that they are being fully completed. In addition, we are considering revising our current client history to better elicit complete responses. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records during the onsite licensing inspection of February 25, 2009, the facility failed to document the type and frequency of service on each treatment plan as required.The findings included:The record sample consisted of seven client records. The type and frequency of services were not documented in client records # 3 and 6. The frequency of services was not documented in client record # 5.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all treatment plan requirements. Clinical supervisors and staff will be re-trained on the proper completion of treatment plans and treatment plan updates with special emphasis placed on including the type and frequency of services. This training will be performed by the Director, William Knecht on 3/24/2009. Treatment plans and treatment plan updates will be reviewed regularly in clinical supervision to assure that they are being fully completed. |
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 the review of client records during the onsite licensing inspection of February 25, 2009, the facility failed to document treatment plan updates which included work on the stated goals of the treatment plan in three of seven client records.The findings included:The record sample consisted of 7 client records. Treatment plan updates in client records #3, 4, and 7 did not reflect progress or lack of progress by the client on the stated goals and objectives of the treatment plans.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all treatment plan requirements. Clinical supervisors and staff will be re-trained on the proper completion of treatment plan updates with special emphasis placed on reviewing the clients progress (or lack thereof) on the stated goals and objectives of the treatment plan. This training will be performed by the Director, William Knecht on 3/24/2009. Treatment plans and treatment plan updates will be reviewed regularly in clinical supervision to assure that they are being fully completed. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of client records during the onsite licensing inspection of February 25, 2009, the facility failed to document progress notes which reflected work on the stated goals of the treatment plan in four of seven client records.The findings included:Seven client records were reviewed. Progress notes in client records #2, 4, 6 and 7 did not reflect work done by the counselor and client relative to the stated goals and objectives of the treatment plans.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all client record requirements. Clinical supervisors and staff will be re-trained on the proper completion of progress notes with special emphasis placed on including more details about the client's progress on treatment plan goals in group notes. This training will be performed by the Director, William Knecht on 3/24/2009. Progress notes will be reviewed regularly in clinical supervision to assure that they are being fully completed. |