This report is a result of an on-site licensure 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 Gettysburg Psychiatric 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 ensure that the clients received counseling services according to their individual treatment plan in four out of seven records reviewed.
Client #1 was admitted on October 28, 2024 and was still active at the time of the inspection. The treatment plan dated November 18, 2024, indicated one hour of individual and three hours of group therapy per week. There was no documentation of the client receiving individual therapy the weeks of November 25, December 2, December 9, and December 16, 2024.
Client #3 was admitted on October 29, 2024 and was still active at the time of the inspection. The treatment plan dated November 18, 2024, indicated one individual therapy session a month and one group therapy a week. There was no documentation that the client received group therapy the week of December 23, 2024.
Client #4 was admitted on August 28, 2024 and discharged on December 11, 2024. The treatment plan dated September 11, 2024, indicated one individual therapy session a week and one group session a month. There was no documentation that the client received individual therapy in the month of October 2024.
Client #6 was admitted on July 31, 2024 and discharged on September 12, 2024. The treatment plan dated August 22, 2024, indicated one individual therapy a week and three group sessions a week. There was no documentation that the client received individual therapy the weeks of August 26, and September 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 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. |