INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted February 15, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Catholic Charities Diocese of Harrisburg was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client charts, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in two out of three applicable client charts reviewed.
Client 1 was admitted on 10/4/2023 and was still active at the time of the investigation. The comprehensive treatment plan dated 11/3/2023 indicated that the client was to receive individual and group therapy on a weekly basis. There was no record of service or individual counseling note from the week of 1/15/2024. Also, there were no records of service or individual and group counseling notes in the client chart for the month of February 2024.
Client 3 was admitted on 11/16/2023 and was still active at the time of the investigation. The comprehensive treatment plan dated 12/12/2023 indicated that the client was to receive individual and group therapy weekly. The last group counseling session note in the client chart was dated 1/30/2024. There were no records of service or counseling notes for weekly groups in February 2024.
This was discussed with facility staff at the time of the complaint investigation.
|
Plan of Correction
Program Director will ensure each client receives counseling services in accordance with their individual treatment plan by:
Reviewing files monthly;
Random audits of client files;
and weekly spot checks of client files.
Services are being provided; however, Program Director will ensure they are properly documented. |
709.53(a)(6) LICENSURE Ind. Tx. Plan
709.53. 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:
(6) Individualized treatment and rehabilitation plan.
|
Observations
Based on a review of the facility ' s Treatment and Rehabilitation Services policy and client charts, the facility failed to follow its policy in two out of three applicable client charts reviewed. The facility ' s policy states that the Individualized Comprehensive Treatment Plan is to be developed within 15 business days.
Client #1 was admitted on 10/4/2023 and was still active at the time of the investigation. The comprehensive treatment plan was developed 11/3/2023. It should have been completed by 10/25/2023.
Client #3 was admitted on 11/16/2023 and was still active at the time of the investigation. The comprehensive treatment plan dated 12/12/2023. It should have been completed by 12/7/2023.
This was discussed with facility staff at the time of the complaint investigation.
|
Plan of Correction
Program Director will ensure each client receives their treatment plan in accordance with the facilities policy by:
Providing clinical staff with due dates for the treatment plan upon admission;
Reviewing treatment plans prior to due date which will endure their completion by the due date.
|