INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Council of Southeast Pennsylvania, Inc. 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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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan, which is to be developed with the client, in three of seven applicable client records reviewed.
Client # 10 was admitted to the outpatient activity on January 17, 2024 and was still active at the time of the inspection. There was no individual treatment and rehabilitation documented in the record at the time of the inspection.
Client # 11 was admitted to the outpatient activity on August 3, 2023 and was discharged on October 15, 2023. There was no individual treatment and rehabilitation documented in the record at the time of the inspection.
Client # 12 was admitted to the outpatient activity on July 13, 2023 and was discharged on December 19, 2023. There was no individual treatment and rehabilitation documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Action steps taken to correct the deficiency:
1. Client # 10-The Comprehensive Treatment Plan was completed on 1/17/24. However, it was not imported to the client's chart in Lauris. This has been rectified. Client #11 - Since the client has been discharged, the deficiency was discussed with the therapist. Client #12 - the client is discharged, and the therapist is no longer with the agency to address the deficiency with.
2. We have requested an addition of "Treatment Plan Completed", "Treatment Plan Update Completed", and "Case Consult Completed" in our Progress Notes from our EHR provider. This will be a required field that prohibits processing of the Progress note. This serves as a reminder for clinical staff.
3. The Clinical Supervisor will run reports to ensure treatment plans are completed as required. This report will be run monthly. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in one of two applicable client records reviewed.
Client # 9 was admitted to the outpatient facility on October 5, 2023 and was still active at the time of the inspection. A treatment plan update was completed on November 9, 2023 and an update was due no later than January 9, 2023; however, the update was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Actions to correct the deficiency:
1.We have requested an addition of "Treatment Plan Completed", "Treatment Plan Update Completed", and "Case Consult Completed" in our Progress Notes from our EHR provider. This will be a required field to ensure that will prohibit the Progress Note from being processed. This serves as a reminder for clinical staff.
2. The Clinical Supervisor will run reports to ensure treatment plans are completed as required. This report will be run monthly.
3. Client was discharged on 2/23/24 and a treatment plan update was not completed. This deficiency was discussed with the therapist and ongoing review of tx plans is now part of supervision.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in two of four applicable client records reviewed.
Client # 8 was admitted to the outpatient activity on January 19, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 19, 2024 and indicated the client was to receive eight weekly group counseling sessions. There were no group counseling sessions documented in the record during the client's entire treatment episode.
Client # 9 was admitted to the outpatient activity on October 5, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 5, 2023 and indicated the client was to receive eight weekly group counseling sessions. There were no group counseling sessions documented in the record during the client's entire treatment episode.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Updates to the treatment plan forms were made on 2/12/2024 to ensure that the services offered to the client are accurately defined in the treatment plan.
The Director of Intervention Services met with clinical staff to review this form change on 2/20/24.
The following steps will be taken to ensure that this deficiency does not recur.
The Clinical Supervisor will review the Treatment Plans for newly admitted clients weekly to ensure that services are listed correctly.
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709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in one of three applicable client records reviewed.
Client # 11 was admitted to the outpatient activity on August 3, 2023 and was discharged on October 15, 2023. There was no follow-up information documented in the record at the time of the inspection.
This is a repeat citation from the April 13, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This citation was reviewed with clinical and support staff on 2/20/24. The follow steps are in place to ensure that the deficiency does not recur:
1. The primary therapist and the administrative assistant will coordinate the completion of follow-up calls each month. This will be accomplished by running a Follow-up Report that has been created in the EHR and creating reminders in their Outlook Calendars to complete the initial and subsequent attempts if applicable.
2. The Clinical Supervisor will audit charts monthly to ensure that successful follow-ups or the required number of attempts to follow-up are documented. |