This report is a result of an on-site licensure renewal inspection conducted on June 13, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Casa de Consejeria y Salud Integral, 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:
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Plan of Correction
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Observations
Based on a review of 7 client records, 3 client records had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.Client #2 was admitted on 3/1/17 and was active at the time of inspection. A treatment plan update was completed 11/1/17 and the next update was due no later than 1/1/18. However, the next update was not completed until 1/10/18. Client #4 was admitted on 3/16/17 and was discharged on 2/23/18. A treatment plan was completed 11/15/17 and the next update was due no later than 1/15/18. However, the next update was not completed until 1/23/18. Client #6 was admitted on 12/8/17 and was discharged on 5/18/18. A treatment plan was completed 3/8/18 and the next update was due no later than 5/8/18. However, the update was not completed as of the date of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will review each treatment plan to ensure that updates are being conducted no later than every 60 days. The clinical supervisor will hold an inservice training to reiterate deadlines of treatment planning per our state and internal standards and policies and procedures. This issue will also be addressed in one-on-one supervisions with each counselor.
Quality assurance will conduct monthly case load audits to identify correct deadlines for treatment plan updates and making sure they are being followed appropriately. Facility director will also make sure during her monthly supervision meetings with quality assurance and clinical supervisors that the in service training is conducted, that the clinical supervisors are addressing it during one-on-one supervisions with the counselors, and that quality assurance is conducting the appropriate audits. This will be implemented immediately and in service will be conducted no later than 7/31/18. |