This report is a result of an on-site licensure renewal inspection: the physical plant inspection was conducted on January 7, 2025, and record review was conducted on January 13, 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 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 client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven records reviewed.
Client #1 was admitted on August 27, 2024 and was still active at the time of the inspection. A treatment plan was completed on September 16, 2024, and the next update was due no later than November 16, 2024; however, it was completed on November 19, 2024.
Client #5 was admitted on April 15, 2024 and discharged on August 30, 2024. A treatment plan was completed on June 26, 2024, and the next update was due no later than August 26, 2024; however, there is no documentation that one was completed.
Client #6 was admitted on August 19, 2024 and discharged on December 20, 2024. A treatment plan was completed on August 28, 2024, and the next update was due no later than October 28, 2024; however, it was completed on November 7, 2024.
Client #7 was admitted on April 26, 2024 and discharged on September 23, 2024. A treatment plan update was completed on May 17, 2024, and the next update was due no later than July 17, 2024; however, it was completed on July 24, 2024.
These findings were reviewed with facility staff during the licensing process.
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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 document treatment plan updates at least every 60 days. Office Administration will ensure ongoing compliance by tracking completion of treatment plans and ensuring that staff are alerted when treatment plan updates are due. The Quality Improvement Department will also complete quarterly chart reviews to monitor ongoing compliance and re-train as needed. |