INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 9, 2017 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:
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Plan of Correction
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709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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
Six client records were reviewed for the partial hospitalization activity on March 9, 2017. The facility failed to specify the type and frequency of counseling services on the individual treatment and rehabilitation plan in client records # 8 and 13.
Client # 8 was admitted into treatment on 1/20/17 and was still active in treatment. The individual treatment and rehabilitation plan documented in the client's record, completed on 2/1/17, did not specify the type and frequency of counseling services.
Client # 13 was admitted into treatment on 4/18/16 and was discharged on 6/28/16. The individual treatment and rehabilitation plan documented in the client's record, completed on 5/27/16, did not specify the type and frequency of counseling services.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all treatment plan requirements. Partial Hospitalization was a recent addition for us in this office. Clinical supervisors and staff have been trained by the Clinical Director on the proper completion of treatment plans and treatment plan updates with special emphasis placed on including the type and frequency of services.
Clinical supervisors will randomly audit files on a weekly basis to assure that all record keeping requirements are being kept. Clinical director will follow up monthly with clinical supervisors to assure continued compliance.
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709.93(a) 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:
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Observations
Seven client records were reviewed for the outpatient activity on March 9, 2017. The facility failed to document a complete client record in client records # 1, 3, 4, and 7.
Client # 1 was admitted into treatment on 11/23/16 and was still active in treatment. A progress note documented in the client's record indicated that the client attended an individual counseling session on 1/11/17. This counseling session was not documented on the client's record of service.
Client # 3 was admitted into treatment on 10/26/16 and was still active in treatment. Progress notes in the client's record indicated that the client attended group counseling sessions on the following dates: 2/27/16, 1/10/17, 1/24/17, 2/7/17, 2/21/17, 2/28/17, and 3/1/17. These counseling sessions were not documented on the client's record of service. In addition, a progress note documented in the client's record, for an individual counseling session attended on 2/2/17, did not document the signature of the counselor.
Client # 4 was admitted into treatment on 7/28/16 and was still active in treatment. A progress note documented in the client's record indicated that the client attended an individual counseling session on 10/3/16. This counseling session was not documented on the client's record of service. In addition, progress notes in the client's record indicated that the client attended group counseling sessions on the following dates: 8/9/17, 9/27/16, 10/4/16, 10/11/16, and 10/18/16. These counseling sessions were not documented on the client's record of service. Lastly, the client's record of service indicated that the client attended a group counseling session on 8/11/16. A progress note for this counseling session was not documented in the client's record.
Client # 7 was admitted into treatment on 8/19/16 and was discharged on 10/24/16. The client's record of service did not document the duration of service for individual counseling sessions attended on the following dates: 8/19/16, 8/24/16, 9/2/16, 9/7/16, and 9/19/16. In addition, a discharge summary was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all requirements regarding having a complete client record. Clinical supervisors and staff have been trained by the Clinical Director on the proper completion of a record log and reminded that all services need to be included in the record of service. Additionally clinical supervisors and staff have been trained by the Clinical Director on the proper completion of a discharge summary. Record # 7 has been updated to include a discharge summary.
Clinical supervisors will randomly audit files on a weekly basis to assure that all record keeping requirements are being kept. Clinical director will follow up monthly with clinical supervisors to assure continue compliance.
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Seven client records were reviewed for the outpatient activity on March 9, 2017. The facility failed to document a physician signature on treatment plans, as imposed by 55 Pa. Code Part III, in client record # 2.
Client # 2 was admitted into treatment on 7/18/16 and was still active in treatment. Treatment for this client was funded through the Medical Assistance program. A treatment plan update documented in the client's record, dated 10/12/16, was not signed by a physician.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all requirements regarding project management services including documenting a physician signature on treatment plans. Clinical supervisors and staff have been trained by the Clinical Director on the proper completion of a treatment plan and reminded to promptly obtain the supervisory physicians approval and signature on all treatment plans.
Clinical supervisors will randomly audit files on a weekly basis to assure that all record keeping requirements are being kept. Clinical director will follow up monthly with clinical supervisors to assure continue compliance.
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