This report is a result of an on-site licensure renewal inspection; the physical plant inspection was conducted on January 8, 2025, and record review was conducted on January 15, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services, 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:
|
Plan of Correction
|
Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of seven records reviewed.
Client #3 was admitted on October 29, 2024 and was still active at the time of the inspection. The treatment plan dated November 6, 2024, indicated one individual therapy session a week. There was no documentation of the client receiving individual therapy the weeks of December 9, 23 and 30, 2024.
Client #4 was admitted on August 7, 2024 and discharged on October 17, 2024. The treatment plan dated August 19, 2024, indicated one individual therapy session and one group therapy session a week. There was no documentation that the client received individual therapy the weeks of September 9, 16 and 23, 2024.
Client #6 was admitted on February 2, 2024 and discharged on May 29, 2024. The treatment plan dated February 20, 2024, indicated two individual therapy session a month and one group session a week. There was no documentation that the client received individual therapy the weeks of March 11, 18 and 25 and April 1, 2024.
Client #7 was admitted on March 15, 2024 and discharged on May 29, 2024. The treatment plan dated April 2, 2024, indicated one individual therapy session a week. There was no documentation that the client received individual therapy the week of April 15, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director of Quality Improvement and Director of Outpatient Operations will ensure that staff are re-trained in an upcoming staff meeting to ensure that counseling services are provided according to the treatment plan. Clinical Supervisors will help ensure ongoing compliance through consultations/supervisions/documentation reviews and the Quality Improvement Department will complete quarterly chart reviews to monitor ongoing compliance and re-train as needed. |