INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 25, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clear Concepts 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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709.92(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 one of two applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client record # 4.Client # 4 was admitted on July 19, 2022 and was discharged October 25, 2022. A treatment and rehabilitation plan was developed on August 20, 2022. A treatment and rehabilitation plan update was due no later than October 20, 2022. There was no documentation of a treatment plan update in the client record.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the April 12, 2022 annual licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed during our agency staff meeting on May 18, 2023. Individual treatment plan updates will be completed at least every 60 days. To ensure completion of treatment plan updates at least every 60 days the Clinical Director and Project Director will verify completion during monthly staff meetings. The Clinical Supervisor will also review individual counselor's client records on a weekly basis. |
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 two of two applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur 60 days after discharge by phone.Client # 4 was admitted on July 19, 2022 and was discharged on October 25, 2022. There was no follow-up information available in the client record. Client # 5 was admitted on February 14, 2022 and was discharged on May 9, 2022. There was no follow-up information available in the client record. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the April 12, 2022 annual licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed with all counselors and support staff during our monthly staff meeting on May 17, 2023. The proper completion of client documentation of follow-up information. Beginning immediately, the follow-up contact information and letter to be sent to the client after 60 days will be given to support staff who will keep information in a binder and will send out letters at the end of 60 days. To ensure correct completion of consent forms the Clinical Director will verify completion during monthly staff meetings. The Clinical Supervisor will also review individual counselor's client records on a weekly basis. |