INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Berks Counseling Center, 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate bathrooms by exhaust fan or window as the bathroom in the office area had a fan that was non-operational and there was no window to act as ventilation.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will request maintenance to repair/replace the exhaust fan. Exhaust fan will be repaired/replaced no later than 6/1/23. The building owner inspected the restroom and verified there is a fully functioning exhaust system that had been temporarily down and has been repaired. The office manager will conduct quarterly checks to ensure that it remains functional. |
705.24 (6) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant inspection, the facility failed to provide toilet paper at each toilet at all times as the bathroom in the office area did not have toilet paper in the wall-mounted dispenser.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Office Manager refilled the toilet paper in this bathroom 3/21/23. The office manager will notify the cleaning company to monitor and ensure adequate toilet paper is available during every clean. |
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 five of seven applicable client records reviewed.
Client #2 was admitted on May 2, 2022 and was still active at the time of the inspection. A treatment plan update was completed on June 7, 2022 and an update was due no later than August 7, 2022; however, the update was not completed October 7, 2022.
Client #4 was admitted on October 15, 2022 and was discharged March 16, 2023. A comprehensive treatment plan was completed on October 21, 2022 and an update was due no later than December 21, 2022; however, the update was not completed until at the time of inspection.
Client #5 was admitted on October 18, 2022 and was discharged February 3, 2023. A comprehensive treatment plan was completed on October 18, 2022 and another update was due no later than December 18, 2022; however, the update was not completed prior to discharge.
Client #6 was admitted on February 3, 2022 and was discharged June 21, 2022. A comprehensive treatment plan was completed February 3, 2022 and another update was due no later than April 3, 2022; however, the update was not completed prior to discharge.
Client #7 was admitted on May 28, 2020 and was discharged on October 14, 2022. A treatment plan update was completed May 23, 2022 and another update was due no later than July 22, 2022; however, the update was not completed until August 8, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will develop a treatment plan training to include timeline expectations and provide to all relevant employees by 6/1/23. This training will be recorded and uploaded to Berks Counseling Center's training management system for all new employees to complete within their first 30 days. Attendance for both will be tracked within BCC's training management system.
Beginning 4/20/23, all clinicians will schedule out all assigned clients for their treatment plan reviews. This will be completed no later than 6/1/23 and will be monitored by Team Leaders.
The treatment plan workflow will be updated by Clinical Director to include scheduling both treatment plan updates and treatment plan reviews in 6 month increments. Scheduling will occur at the conclusion of each treatment plan update. Workflow will be completed and disseminated to staff by 6/1/23. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of patient records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction documenting that treatment and rehabilitation plans shall be reviewed and updated at least every sixty days were submitted and approved by the Department for the July 30, 2021, March 9, 2021, and February 15, 2022 annual licensing inspections. Failing to document that treatment and rehabilitation plans shall be reviewed and updated at least every sixty days was again found to be a deficiency in the March 20, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Berks Counseling Center did follow the previous plans of correction and achieved some success; however there continue to be areas of concern.
CQI Staff will conduct quarterly reviews by hand while BCC builds a report that will allow for weekly CQI reviews.
Berks Counseling Center has contracted with Mission Driven Data and the CQI Director will meet with them to identify if they can assist with report development.
CQI reviews will occur on a weekly basis no later than 6/1/23. The frequency of CQI reviews will decrease as compliance increases, but will never occur less than 1x/quarter. |