INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clear Concepts 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
DDAP staff observed that the landing of the second story rear staircase was deteriorating and created a potential slip, trip and fall hazard.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard by the end of August 2025. During the physical plant inspection on 4/8/2025 the landing of the second story rear staircase deteriorated. The Project Director has reached out to 3 contractors and is waiting to hear from the contractors with estimates. The Project Director has placed a "watch your step" sign on the back door to warn people the landing step has a loose board. |
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 document treatment plan updates within the regulatory timeframe in four out of six applicable records reviewed.
Client #1 was admitted on July 11, 2024, and was still active at the time of the inspection. A treatment plan update was completed on October 11, 2024, and the next update was due no later than December 11, 2024; however, it was completed January 9, 2025.
Client #2 was admitted on July 29, 2024, and was still active at the time of the inspection. A treatment plan update was completed on October 21, 2024, and the next update was due no later than December 21, 2024; however, it was completed on January 2, 2025.
Client #5 was admitted on August 29, 2024, and discharged on January 15, 2025. A treatment plan update was completed on September 30, 2024, and the next update was due no later than November 30, 2024; however, it was completed on December 1, 2024.
Client #6 was admitted on July 22, 2024, and was discharged on January 15, 2025. A treatment plan update was completed on October 22, 2024, and the next update was due no later than December 22, 2024; however no further treatment plan updates were documented.
This is a repeat citation from the April 9, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed during our agency staff meeting on May 15, 2025. The Clinical Supervisor and Project Director met with the counselors of client records #1, 2, 5 and 6 to ensure the treatment plan updates will be completed every 60 days as per the agency policy. To ensure completion of treatment plan updates at least every 60 days the Project Director will review charts on a weekly basis to verify completion. The Clinical Supervisor will also review the individual counselor's client records on a weekly basis to ensure compliance. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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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 four out of seven records reviewed.
Client #1 was admitted on July 11, 2024, and was still active at the time of the inspection. A treatment plan dated August 13, 2024, indicated one group therapy session per week. There was no documentation that the client received group sessions between August 13, 2024 through April 8, 2025.
Client #2 was admitted on July 29, 2024, and was still active at the time of the inspection. A treatment plan completed October 21, 2024, indicated two individual therapy sessions per month. During the months of November and December 2024, only one individual therapy session was documented in the client record for each month.
Client #3 was admitted on October 17, 2024, and was still active at the time of the inspection. A treatment plan completed November 17, 2024, indicated two individual therapy sessions per month. During the month of December 2024, only one individual therapy session was documented.
Client #5 was admitted on August 29, 2024, and was discharged on January 15, 2025. A treatment plan dated September 30, 2024, indicated one individual therapy session per week. There was no documentation in the client record to verify that an individual session had been completed during the weeks of: November 10-16, 2024, November 24-30, 2024, December 8-14, 2024, and December 22-28, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and policy will also be reviewed with all counselors by the Project Director during the agency staff meeting on May 15, 2025. The proper completion and timing of completion of client treatment plans as well as ensuring the client is receiving the services that are documented in the agreed upon signed treatment plan. To ensure clients are receiving the counseling services according to their individual treatment plan the Project Director will review charts on a weekly basis to verify completion. The Clinical Supervisor will also review the individual counselor's client records on a weekly basis to ensure compliance. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of seven records reviewed. The facility's policy and procedures manual states that case consultations will be completed every ninety days.
Client #1 was admitted on July 11, 2024, and was still active at the time of the inspection. A case consultation was completed July 11, 2024, the next consultation was due no later than October 11, 2024; however, there were no further case consultations documented in the client record.
Client #3 was admitted on October 17, 2024, and was still active at the time of the inspection. A case consultation was completed October 20, 2024, the next consultation was due no later than January 20, 2025; however, there were no further case consultations documented in the client record.
Client #5 was admitted on August 29, 2024, and was discharged on January 15, 2025. A case consultation was completed August 29, 2024, the next consultation was due no later than November 29, 2024; however, there were no further case consultations documented in the client record.
Client #6 was admitted on July 22, 2024, and was discharged on January 15, 2025. A case consultation was completed July 22, 2024, the next consultation was due no later than October 22, 2024; however, there were no further case consultations documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately.
This standard and policy will also be reviewed with all counselors by the Project Director during the agency staff meeting on May 15, 2025. The proper completion and timing of completion of client case consultation notes will be reviewed with all staff during our agency staff meeting on May 15, 2025.
To ensure counselors complete case consultation notes for all active clients the Project Director will review charts on a weekly basis to verify completion. The Clinical Supervisor will also review the individual counselor's client records on a weekly basis to ensure compliance.
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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 provide a complete client record, which is to include aftercare information in two out of three applicable discharged records reviewed. The facility's policy is to document aftercare plans for all successfully discharged clients.
Client #4 was admitted on July 29, 2024, and was discharged on November 18, 2024. There was no aftercare plan documented in the client record.
Client #6 was admitted on July 22, 2024, and was discharged on January 15, 2025. There was no aftercare plan documented in the client record.
Theses findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed during our agency staff meeting on May 15, 2025. To ensure completion of aftercare care plans for all clients who have "successfully completed" treatment the Project Director will review this policy and procedure with all staff during the agency staff meeting on May 15, 2025. The Project Director will review closed client charts to ensure aftercare plans are completed before they are filed in archive. |