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 14, 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 #2 was admitted on September 13, 2024 and was still active at the time of the inspection. A treatment plan was completed on October 1, 2024, and the next update was due no later than December 1, 2024; however, it was completed on December 10, 2024.
Client #4 was admitted on April 9, 2024 and discharged on July 17, 2024. A treatment plan was completed on May 9, 2024, and the next update was due no later than July 9, 2024; however, there is no documentation that one was completed.
Client #5 was admitted on February 27, 2024 and discharged on August 9, 2024. A treatment plan was completed on April 30, 2024, and the next update was due no later than June 30, 2024; however, there is no documentation that one was completed.
Client #6 was admitted on May 8, 2024 and discharged on November 18, 2024. A treatment plan was completed on June 4, 2024, and the next update was due no later than August 4, 2024; however, it was completed on September 6, 2024. The next update was due no later than November 6, 2024; however, it was completed on November 9, 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. |