INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 24, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Anthony Pater 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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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to include the duration of the services provided on the record of services observed in 8 of 8 client records.
The findings include:
Eight client records were reviewed on October 24, 2012. There was no documentation of the duration of the service on the Record of Services documents in all eight client records reviewed.
The finding was addressed with the Sole Proprietor who did not dispute the findings.
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Plan of Correction
The sole proprietor shall create a record of service which quantifies the amount of time one unit is equivalent to. This will be clearly printed in each record of service utilized for newly admitted clients on and after December 1, 2012.
One unit for individual, group or family session shall equal 15 minutes.
One unit for an assessment shall equal 90 minutes. |
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 document an aftercare plan in two of four client records where aftercare plans were required.
The findings include:
Eight client records were reviewed on October 24, 2012. Four client records were required to include documentation of an aftercare plan. There was no documentation of an aftercare plan in client records # 1 and # 7. Facility policy and procedure stipulates that aftercare plans are to be completed with the client two to four sessions prior to successful discharge.
Client # 1 was admitted on February 23, 2012. The client was successfully discharged on September 11, 2012. There was no documentation of an aftercare plan in the client's record as of October 24, 2012.
Client # 7 was admitted on March 20, 2012. The client was successfully discharged on September 19, 2012. There was no documentation of an aftercare plan in the client's record as of October 24, 2012.
The findings were addressed with the Sole Proprietor and were not disputed.
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Plan of Correction
In order to adhere to the existing policy, the sole proprietor shall add a statement to the current chart order. The check box which currently reads "Aftercare Plan" will be changed to read "Aftercare Plan (distributed to client two to four sessions prior to successful discharge)". An additional checkbox reading "Aftercare Plan (reviewed and completed)" will be added to the chart order. These changes to the chart order will be utilized for all newly admitted clients on and after December 1, 2012 |