INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 27, 2014 by staff from the Program Licensure Division. Based on the findings of the on-site inspection, Pennsylvania Counseling Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document follow-up attempts in three of the five records reviewed.
The findings include:
Ten client records were reviewed on January 27, 2014. Five of the ten client records were for discharged clients and were required to have documentation of follow-up attempts. Follow-up was not documented in client records, #7, 9 and 10.
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Plan of Correction
The Facility Director will oversee that all staff are re-educated to document follow-up for discharged clients. The Director of Quality Improvement will conduct random chart reviews to ensure ongoing compliance. |