This report is a result of an on-site licensure renewal inspection; the physical plant inspection was conducted on January 8, 2025, and record review was conducted on January 15, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services Lancaster County 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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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of seven records reviewed.
Client #3 was admitted on November 7, 2024 and was still active at the time of the inspection. The treatment plan dated November 20, 2024, indicated two individual therapy sessions a month and one group therapy per week. There was no documentation of the client receiving individual therapy in the month of December 2024 and no group therapy the week of December 23, 2024.
Client #5 was admitted on May 2, 2024 and discharged on July 22, 2024. The treatment plan dated May 10, 2024, indicated one individual therapy session and one group therapy session a week. There was no documentation that the client received group therapy the months of May and June 2024.
Client #6 was admitted on February 1, 2024 and discharged on May 31, 2024. The treatment plan dated March 7, 2024, indicated two individual therapy sessions a month and one group session a week. There was no documentation that the client received group therapy the months of March and April 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director of Quality Improvement and Director of Outpatient Operations will ensure that staff are re-trained in an upcoming staff meeting to ensure that counseling services are provided according to the treatment plan. Clinical Supervisors will help ensure ongoing compliance through consultations/supervisions/documentation reviews and the Quality Improvement Department will complete quarterly chart reviews to monitor ongoing compliance and re-train as needed. |