INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 12, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Crossroads Counseling 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 and a plan of correction is due on November 12, 2007.
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Plan of Correction
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709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records the facility failed to achieve compliance with this regulation. Client Records # 1, 2, 3 and 4 documented on brief and incomplete family histories, sexual histories and educational histories. The total sample reviewed was four records.
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all intake and admission record keeping requirements. We recognize that client histories need to be complete and include a comprehensive personal history. These histories should include complete family histories, sexual histories and educational histories. Staff have been re-trained on the requirements for completing comprehensive client histories. In addition, supervisors have been re-trained to monitor the completion of these client histories to assure that they will be thorough and complete. The executive director, William Knecht, will oversee the clinical supervisors to assure that this is completed. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records it was determined that the facility failed to meet this regulation as evidenced by documentation of treatment plan updates at 60 day intervals rather than at the required 30 day interval in three of three applicable client records reviewed ( # 2, 3 and 4). The total record sample consisted of four client records.
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all treatment planning requirements. We recognize that treatment plan updates need to be completed every 30 days on clients participating in the Partial Hospitalization level of care. Staff have been re-trained on the time frames for proper completion of treatment plans and treatment plan updates. In addition, supervisors have been re-trained to monitor client treatment plans to assure that they will be completed within the proper timeframes. The executive director, William Knecht, will oversee the clinical supervisors to assure that this is completed. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records it was determined that the facility failed to provide for at least two individual counseling sessions a week. Three of four client records reviewed, #2, 3, and 4, contained documentation revealing that only one individual treatment session was provided each week during the time period that each client was treated at the partial hospital level of care.
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all treatment and rehabilitation requirements. We recognize that individual sessions need to be conducted twice every week on clients participating in the Partial Hospitalization level of care. Staff have been re-trained on the requirements for providing individual counseling on clients participating in this level of care. In addition, supervisors have been re-trained to monitor the scheduling of individual sessions to assure that they will be completed within the proper timeframes. The executive director, William Knecht, will oversee the clinical supervisors to assure that this is completed. |
709.83(a)(10) LICENSURE Client records
709.83. 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:
(10) Discharge summary.
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Observations
Based on a review of client records it was determined that the facility failed to meet this regulation as evidenced by incomplete information in the discharge summary in client record # 1. The type of services offered to the client was described only as "IOP" and did not include any further description of the various specific services offered such as individual, group, and family. This was the only applicable client record in the sample of four records that was in a discharged status.
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Plan of Correction
Crossroads Counseling, Inc. intends to fully comply with all record keeping requirements, specifically those regarding discharge summaries. We recognize that discharge summaries need to be complete and include specific services offered such as individual, group, and family. Staff have been re-trained on the requirements for completing discharge summaries. In addition, supervisors have been re-trained to monitor the completion of discharge summaries to assure that they will be thorough and complete. The executive director, William Knecht, will oversee the clinical supervisors to assure that this is completed.
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