INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23, 24 and 26, 2009 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 March 23, 2009.
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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 during the onsite inspection of February 23, 24 and 26, 2009, the facility failed to document personal histories which addressed family dynamics, and educational history.. The findings include:Two client records representing the partial hospitalization level of care were reviewed during the on site inspection. Client records # 14 and 15 did not include documentation of family dynamics . Each of the client records alluded to a family history of addictions but did not document details about the extent of the addictions or the impact on the family in general and the client in particular. Educational histories in these two client records did not document school relationships or disciplinary issues.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with the intake and admission documentation requirements. Clinical supervisors and staff will be re-trained on the proper completion of client histories, with specific emphasis placed on education history, employment history, and sexual history. This training will be performed by the Director, William Knecht on 3/24/2009. Client histories will be reviewed regularly in clinical supervision to assure that they are being fully completed. In addition, we are considering revising our current client history to better elicit complete responses. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of the client records during the onsite licensing inspection held February 23, 24 and 26, 2009, the facility failed to document psychosocial evaluations which included coping mechanisms and support systems in two of two client records.The findings include: Two client records for the partial hospitalization level of care were reviewed during the onsite licensing inspection. Client records # 14 and 15 did not include documentation of the client's support systems. Client record # 14 failed to document the client's coping mechanisms in the psychosocial evaluation.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with the intake and admission documentation requirements. Clinical supervisors and staff will be re-trained on the proper completion of psychosocial evaluations, with specific emphasis placed on including details about client coping mechanisms and support systems. This training will be performed by the Director, William Knecht on 3/24/2009. Client histories will be reviewed regularly in clinical supervision to assure that they are being fully completed. In addition, we are considering revising our current psychosocial evaluation to better elicit complete responses. |
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 the review of the client records during the onsite licensing inspection held February 23, 24 and 26, the facility failed to document the required thirty day treatment plan updates in each client record in two of two client records. The findings include: Two client records were reviewed at this level of care. Client records # 14 & 15 did not include documentation of thirty day treatment plan updates.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all treatment plan requirements. Clinical supervisors and staff will be re-trained on the proper completion of treatment plans and treatment plan updates with special emphasis placed on the proper timeframes for updates while clients are participating in the PHP level of care. This training will be performed by the Director, William Knecht on 3/24/2009. Treatment plans and treatment plan updates will be reviewed regularly in clinical supervision to assure that they are being fully completed. |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of the client records, the facility failed to document consents to release information which identified the specific information to be released to funding entities and exceeded the information approved by the client on the form when releasing client related information. The findings included:A sample of 17 client records was reviewed during the onsite licensing inspection of February 23-26, 2009 . The consents to release information forms documented in client records # 1, 2, 5, 11, 12, 14, 15 and 17 identified information to be released under the heading of "billing information" . This descriptor on the consent to release information form did not include the specific pieces of information to be included in the billing information which were to be released. Consent to release information forms in these records only identified the following pieces of information which would be released by the agency: admission, attendance, diagnosis and billing information. The clients signed these releases as written. Actual information released included information related to the clients progress in treatment, abstinence and support systems. One client record ,# 12, documented a release of information which exceeded the limitations set at 4 Pa. Code subsection 255.5(b) by releasing the names of the medications taken by the client.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all state and federal confidentiality laws. The consent forms in question have been updated to identify the specific information being released. The language that is now being used follows PA Code 255.5 exactly. William Knecht, Director, will perform a staff training on the new forms on 3/24/2009. Consent forms will be reviewed regularly in clinical supervision to assure that they are being completed accurately. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. 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 the review of client records, the facility failed to include documentation of family dynamics, educational histories and employment histories in the personal histories in 14 of 17 client records. The findings include:Seventeen client records were reviewed during the onsite licensing inspection conducted on February 23, 24 and 26. Each of the client records reviewed was in the outpatient level of care at the time of the inspection. Family relationships were not described in client records # 1, 2, 3, 4, 5, 7, 9, 10, 12, 13, 14, 15 and 17. Educational histories were incomplete in client records # 1, 2, 3, 4, 5, 7, 9, 10, 12, 13, 14, 15 and 17. Employment histories did not document a complete record of the individual's employment ,dates of employment, details related to performance or reasons for separation in client records # 2, 3 and 8.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with the intake and admission documentation requirements. Clinical supervisors and staff will be re-trained on the proper completion of client histories, with specific emphasis placed on education history, employment history, family history, and sexual history. This training will be performed by the Director, William Knecht on 3/24/2009. Client histories will be reviewed regularly in clinical supervision to assure that they are being fully completed. In addition, we are considering revising our current client history to better elicit complete responses. |
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 the review of client records, the facility failed to document treatment plan updates which documented the client's progress or lack of it relative to the treatment plan goals in four of seventeen client records.The findings included: Seventeen client records were reviewed during the on site licensing inspection of February 23, 24 and 26, 2009 . Each of the clients represented was either involved in the outpatient level of care or had been discharged from the outpatient program. Client records # 2, 6, 10 and 11 documented treatment plan updates which did not address the client's progress on the stated goals of their treatment plans.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all treatment plan requirements. Clinical supervisors and staff will be re-trained on the proper completion of treatment plan updates with special emphasis placed on reviewing the clients progress (or lack thereof) on the stated goals and objectives of the treatment plan. This training will be performed by the Director, William Knecht on 3/24/2009. Treatment plans and treatment plan updates will be reviewed regularly in clinical supervision to assure that they are being fully completed. |