INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on February 18-19, 2020. Based on the findings of the on-site inspection, Crossroads Counseling, Inc was found to not 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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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of eight out of eight records reviewed during a licensing inspection conducted on February 19, 2020, the project failed to provide a complete client rights policy and procedure to include reasons for removing sections shall be documented in the record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all requirements regarding client rights and proper notification of policies. The client rights brochure, which is what was reviewed, is just a summary of key client rights. It was never meant to be a complete list. Clients are informed of their full rights at the time of orientation and provided access to the entire client records access policy. However, effective 3/5/2020, the clients rights brochure has been updated to specifically state that "There may be circumstances where the agency may temporarily remove portions of the client record prior to presenting it to you if it's determined that the information may be detrimental to you". Additionally, it's been updated to specifically state that "You also have the right to submit additional information to be included in your records including rebuttal data or memoranda". |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of eight out of eight records reviewed during a licensing inspection conducted on February 19, 2020, the project failed to provide a complete client rights policy and procedure to include clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all requirements regarding client rights and proper notification of policies. The client rights brochure, which is what was reviewed, is just a summary of key client rights. It was never meant to be a complete list. Clients are informed of their full rights at the time of orientation and provided access to the entire client records access policy. However, effective 3/5/2020, the clients rights brochure has been updated to specifically state that "There may be circumstances where the agency may temporarily remove portions of the client record prior to presenting it to you if it's determined that the information may be detrimental to you". Additionally, it's been updated to specifically state that "You also have the right to submit additional information to be included in your records including rebuttal data or memoranda". |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of four buprenorphine patient records on February 18-19, 2020, the narcotic treatment program failed to provide one patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
Patient #3 was admitted on January 10, 2019 and was current at the time of the inspection. Patient #3 had 0.5 hours of individual therapy in January 2020, 0.5 hours of individual therapy in December 2019, 0.5 hours of individual therapy in November 2019, 20 minutes of individual therapy in October 2019, 0.5 hours of individual therapy in September 2019, 0.5 hours of individual therapy in August 2019, 0.5 hours of individual therapy in August 2019 and 1 hour of individual therapy in July 2019.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Crossroads Counseling, Inc intends to fully comply with all psychotherapy requirements for clients receiving MAT services.
Effective 3/5/2020, all MAT clients will receive a minimum of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. If a client is unwilling or unable to comply, they will be discharged from the program and/or referred to another MAT provider. Attendance will be reviewed at every MAT appointment as well as be regularly reviewed in weekly clinical supervision as well as through random file audits. Director will follow up monthly with clinical supervisors to assure continued compliance.
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