This report is a result of an on-site licensure renewal inspection conducted on February 3, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services, 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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Observations
Based on a review of client records on February 3, 2022, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven client records reviewed.
Client #1 was admitted on June 16, 2021 and was current at the time of the inspection. A treatment plan update was completed on November 8, 2021, and the next update was due by January 7, 2022; however, was not completed until January 10, 2022.
Client #4 was admitted on September 15, 2021 and was current at the time of the inspection. A treatment plan update was completed on October 27, 2021, and the next update was due by December 26, 2021; however, was not completed until December 29, 2021.
Client #5 was admitted on August 3, 2021 and was discharged on December 27, 2021. A treatment plan update was completed on September 1, 2021, and the next update was due by October 31, 2021; however, was not completed until November 3, 2021.
Client #6 was admitted on October 15, 2021 and was discharged on January 21, 2022. A treatment plan update was completed on November 5, 2021, and the next update was due by January 4, 2022; however, was not completed until January 7, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Director of Outpatient Administration re-trained all program staff on treatment plan timeframes during a team meeting on 2/8/2022. The Office Manager will be responsible for ongoing compliance and will track the completion of treatment plans for all clients. The Office Manager will oversee that clinical staff are re-educated as needed to review and update treatment plans at least every 60 days. |