INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 4, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Harbor 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to provide group counseling in an area that could not be seen outside the counseling room. The counseling room can be viewed from a 2nd floor hallway door with a window in it. This finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director will facilitate purchasing and installing an opaque vinyl cling which will adhere to the window in the door in the second-floor hallway, completely covering the window and making it impossible to see anything but light through it. |
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 clients received counseling services according to their individual treatment and rehabilitation plan in five out of seven charts reviewed. Client #1 was admitted on March 26, 2021 and was discharged on December 9, 2021. The comprehensive treatment plan, dated April 23, 2021, indicated one individual session per week. The record of services and progress notes indicated that the client had received no individual session from April 24, 2021 to May 26, 2021 and from May 26, 2021 to June 21, 2021. Client #2 was admitted on June 1, 2021 and was discharged on December 20, 2021. The comprehensive treatment plan, dated October 15, 2021, indicated one group per week (or four groups per month). The record of service and progress notes indicated that the client received no group sessions between October 15, 2021 and December 14, 2021. Client #4 was admitted on August 13, 2021 and was active at the time of the inspection. The comprehensive treatment plan, dated September 9, 2021, indicated two group sessions per week (or eight groups per month). The record of service and progress notes indicated that the client did not receive two groups per week from September 27, 2021 and November 7, 2021. Client #5 was admitted on June 24, 2021 and was active at the time of the inspection. The comprehensive treatment plan, dated July 23, 2021, indicated four group sessions per week (or 16 groups per month). The record of service and progress notes indicated that the client had received no group sessions between August 14, 2021 and August 25, 2021 and between August 27, 2021 and September 9, 2021. Client #6 was admitted on August 2, 2021 and was active at time of the inspection. The comprehensive treatment plan, dated August 16, 2021, indicated one individual session per week. The record of service and progress notes indicated that the client had received no individual sessions between September 6, 2021 and September 23, 2021. These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
While reviewing individual treatment plans the agency's clinical supervisor will place an emphasis on making sure the counseling services provided reflect the individualized treatment plan. If it is found the services provided or attended do not reflect an individual's treatment plan, the clinical supervisor will inform the individual's primary counselor. The primary counselor will then take action resulting in the treatment plan reflecting the individual's treatment. This could be updating the treatment plan, following up with the client, or any other helpful intervention. The clinical supervisor will reinforce the importance of the individual's treatment plan reflecting services provided to the individual during clinical staff meetings and during clinical supervision. |
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 case consultations according to the facility's written policy and procedure manual in three out of seven applicable records reviewed. The facility's policy manual indicated case consultations would be documented every ninety days after the client is admitted to treatment and would be completed annually after one year. Client #3 was admitted on June 28, 2021 and discharged on October 4, 2021. Client #3 did not have a case consult completed. Client #5 was admitted on June 24, 2021 and a case consult was due on September 24, 2021 per their policy and was completed on November 11, 2021. Client #7 was admitted on May 6, 2021 and a case consult was due on August 6, 2021 per their policy and was completed on August 17, 2021. These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
During clinical supervision the clinical supervisor will use the agency's EMR's CAM Dashboard to remind clinicians of upcoming case consultations. Clinicians will then conduct case consultations during clinical staff meetings or during clinical supervision, along with the required documentation. The clinical supervisor will reinforce the importance of conducting case consultations every ninety days during clinical staff meetings and during clinical supervision. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a client follow up according to the facility's written policy and procedure manual in one out of three applicable records reviewed. The facility's policy manual indicated follow ups would be documented within one week of client discharge. Client #3 was admitted on June 28, 2021 and was discharged on October 4, 2021. No follow up was documented in the client record. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will conduct a staff training on the agency's discharge policy. This training will focus on all documentation and policies regarding discharge including but not limited to discharge summary, aftercare planning, and follow-up. A particular emphasis will be placed on the agency's policy of discharge follow-up attempts being conducted within one week of individuals discharged due to referral to another agency and one month for all other types of discharge. |