INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 4, 2025 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on an administrative review of the March 2024 through December 2024 fire drill logs, the facility failed to ensure their written fire drill logs included the documentation of which exit route was used during fire drills.
At the time of the review, the exit route used was not documented on the March 2024, June 2024, September 2024, and November 2024 fire drill logs.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill paperwork has been updated to include a map of the facility to ensure exit route is documented. The office manager will ensure compliance. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 3 was admitted on September 16, 2024 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/4/25, the Department Leaders will re-train all relevant staff on required releases of information, especially for the payor. Department Leaders, Team Leaders, and the CQI Department will be responsible for monitoring this via monthly chart reviews. The client identified in the review has been discharged; however an alert has been placed on his chart indicating that information cannot be released to the payor. |
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 ensure all treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of three applicable client records reviewed.
Client # 1 was admitted on August 21, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 26, 2024 and the first update was due no later than November 26, 2024; however, the update was not completed until December 18, 2024.
Client # 3 was admitted on September 16, 2024 and was still active at the time of the inspection. A treatment plan update was completed on October 22, 2024 and the next update was due no later than December 22, 2024; however, the update was not completed until January 21, 2025.
Client # 4 was admitted on August 9, 2024 and was discharged on December 3, 2024. The individual treatment plan was completed on September 24, 2024 and the first update was due no later than November 24, 2024; however, the update was not completed until December 2, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The staff cited will receive re-training for treatment planning by 3/31/25.
2. BCC will finalize a treatment plan tool that has been developed, and train Clinical Care Coordinators to use it by 3/31/25.
3. Department Leaders and Clinic Director will review the treatment plan workflow for necessary edits and implement by 3/31/25.
The Department Leaders, Team Leaders, and CQI Department will be responsible for ongoing compliance via monthly chart reviews. |