INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 30, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Harbor Counseling 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 outpatient client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days following admission.Client #1 was admitted on June 24, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than July 24, 2024; however, it was not completed until August 29, 2024.Client #2 was admitted on April 3, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than May 3, 2024; however, it was not completed until June 5, 2024.Client #6 was admitted on March 20, 2024 and was discharged on June 10, 2024. A comprehensive treatment plan was due no later than April 20, 2024; however, it was not completed until June 10, 2024.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To ensure that a master treatment plan is completed within 30 days of a client's admission to treatment, Harbor Counseling will take the following steps:
1. Staff Training
Action: Conduct mandatory training sessions for all clinical staff on the importance of timely completion of master treatment plans and lead the staff in a thorough review of the facility's policy and procedures regarding treatment planning.
Responsible Party: Clinical Supervisor
Timeline: Within 2 weeks (12/3/24)
2. Monitoring and Accountability
Action: Implement a tracking system to monitor the status of treatment plans for all clients. This system will include alerts for approaching deadlines.
Responsible Party: Clinical Supervisor
Timeline: Within 2 weeks (12/3/24)
3. Regular Audits
Action: Conduct weekly audits of client files to ensure compliance with the 30-day requirement.
Responsible Party: Management Team
Timeline: Ongoing - beginning on 11/22/24
4. Feedback Mechanism
Action: Establish a feedback mechanism for staff to report any challenges or barriers to completing treatment plans on time.
Responsible Party: Clinical Supervisor
Timeline: Within 1 week
5. Performance Reviews
Action: Include the timely completion of treatment plans as a key performance indicator in staff evaluations.
Responsible Party: Project Director
Timeline: Within 1 month (12/19/24)
6. Client Involvement
Action: Engage clients in the treatment planning process to ensure their input and cooperation, which can expedite the completion of the plan.
Responsible Party: Primary Therapist
Timeline: Ongoing ? beginning 11/22/24
7. Documentation and Reporting
Action: Maintain detailed records of all completed treatment plans and any instances of non-compliance, including reasons and corrective actions taken.
Responsible Party: Management Team
Timeline: Ongoing - beginning 11/22/24
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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 outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of five records reviewed.Client #3 was admitted on February 28, 2024 and was still active at the time of the inspection. A treatment plan update was completed on July 2, 2024 and an update was due no later than September 2, 2024; however, none was completed.Client #5 was admitted on March 21, 2024 and was discharged on September 6, 2024. A comprehensive treatment plan was completed on April 3, 2024 and an update was due no later than June 3, 2024; however, it was not completed until August 28, 2024. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To ensure that treatment plan updates are completed every 60 days for all clients, Harbor Counseling will take the following steps:
1. Staff Training
Action: Provide training sessions for all clinical staff on Harbor Counseling's policies and procedures regarding the due dates of treatment plan updates, reinforce the importance that they are done every 60 days.
Responsible Party: Clinical Supervisor
Timeline: Within 2 weeks (12/3/24)
2. Tracking System Implementation
Action: Develop and implement a tracking system to monitor the due dates for treatment plan updates. This system will include automated reminders for staff.
Responsible Party: Clinical Supervisor with assistance from EMR software vendor
Timeline: Within 3 weeks (12/10/24)
3. Regular Audits
Action: Conduct bi-weekly audits of client files to ensure compliance with the 60-day update requirement.
Responsible Party: Management Team
Timeline: Ongoing beginning on 11/22/24
4. Supervisory Oversight
Action: Assign supervisors to review and approve treatment plan updates to ensure they are completed on time.
Responsible Parties: Clinical Supervisor, Clinical Director
Timeline: Ongoing beginning 11/22/24
5. Feedback and Support
Action: Create a feedback system for staff to report any issues or obstacles in updating treatment plans and provide support to address these challenges.
Responsible Party: Clinical Supervisor
Timeline: Within 1 week (11/26/24)
6. Performance Metrics
Action: Incorporate the timely completion of treatment plan updates into staff performance evaluations.
Responsible Party: Project Director
Timeline: Within 1 month (12/19/24)
7. Client Engagement
Action: Involve clients in the treatment plan update process to ensure their active participation and timely completion.
Responsible Party: Primary Therapist
Timeline: Ongoing beginning 11/22/24
8. Documentation and Reporting
Action: Maintain comprehensive records of all treatment plan updates and instances of non-compliance, including reasons and corrective actions taken.
Responsible Party: Management Team
Timeline: Ongoing beginning 11/22/24
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document after care information within guidelines established by the facility's policy and procedures manual in one out of one applicable records reviewed. The facility's policy and procedures manual states that the after care plan must be completed prior to discharge.Client #5 was admitted on March 31, 2024 and was discharged on September 6, 2024. No after care plan was documented.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure that aftercare plans are completed with all clients who are discharged successfully, Harbor Counseling will follow the following steps:
1. Staff Training
Action: Conduct training sessions for all clinical staff on the importance of aftercare planning and provide a review of Harbor Counseling's discharge policy as well as the forms available in our EMR software to track discharge planning.
Responsible Party: Clinical Supervisor
Timeline: Within 2 weeks (12/3/24)
2. Client Involvement
Action: Engage clients in the aftercare planning process early in their treatment to ensure they understand and are prepared for their aftercare plan.
Responsible Party: Primary Therapist
Timeline: Ongoing beginning 11/22/24
3. Regular Audits
Action: Conduct monthly audits of discharge records to ensure compliance with the aftercare planning requirement.
Responsible Party: Management Team
Timeline: Ongoing beginning 11/22/24
4. Supervisory Oversight
Action: Assign supervisors to review and approve aftercare plans before client discharge.
Responsible Parties: Clinical Supervisor, Clinical Director
Timeline: Ongoing beginning 11/22/24
5. Feedback Mechanism
Action: Establish a feedback system for clients and staff to report any issues or barriers in the aftercare planning process.
Responsible Party: Clinical Supervisor
Timeline: Within 1 week (11/26/24)
6. Performance Reviews
Action: Include the completion of aftercare plans as a key performance indicator in staff evaluations.
Responsible Party: Project Director
Timeline: Within 1 month (12/19/24)
7. Continuous Improvement
Action: Regularly review and update the aftercare planning process based on feedback and audit results to ensure it remains effective.
Responsible Party: Management Team
Timeline: Ongoing beginning 11/22/24
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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 outpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 30 days following discharge.Client #5 was admitted on March 31, 2024 and was discharged on September 6, 2024. No follow up was documented.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure that follow-up communication with discharged clients is done and documented in the client record, Harbor Counseling will follow the following steps:
1. Staff Training
Action: Conduct training sessions for all clinical and administrative staff on Harbor Counseling's follow-up policy and procedure for discharged clients and the importance of documenting follow-up communication.
Responsible Party: Clinical Supervisor
Timeline: Within 2 weeks (12/3/24)
2. Tracking System Implementation
Action: Implement a tracking system to monitor follow-up communications and ensure they are documented in the client records.
Responsible Party: Clinical supervisor using EMR software
Timeline: Within 3 weeks (12/10/24)
3. Regular Audits
Action: Conduct monthly audits of client records to ensure follow-up communications are documented as required.
Responsible Party: Management Team
Timeline: Ongoing beginning 11/22/24
4. Supervisory Oversight
Action: Assign supervisors to review and verify that follow-up communications are documented in the client records.
Responsible Parties: Clinical Supervisor, Clinical Director
Timeline: Ongoing beginning 11/22/24
5. Feedback Mechanism
Action: Establish a feedback system for staff to report any challenges or barriers in documenting follow-up communications.
Responsible Party: Clinical Supervisor
Timeline: Within 1 week (11/26/24)
6. Performance Reviews
Action: Include the documentation of follow-up communications as a key performance indicator in staff evaluations.
Responsible Party: Project Director
Timeline: Within 1 month (12/19/24)
7. Client Engagement
Action: Inform clients about the follow-up communication process during discharge planning to ensure their cooperation and understanding.
Responsible Party: Primary Therapist
Timeline: Ongoing beginning 11/22/24
8. Continuous Improvement
Action: Regularly review and update the follow-up communication documentation process based on feedback and audit results to ensure it remains effective.
Responsible Party: Management Team
Timeline: Ongoing beginning 11/22/24
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