INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10, 2008 through April 11, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mainstream Counseling, 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 and a plan of correction is due on May 12, 2008.
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Plan of Correction
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation and staff interview, the facility failed to document an audit within six months of the end of the fiscal year. The project's fiscal year ended on 6/30/07. The audit was not completed.
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Plan of Correction
By end of fiscal year 2007-2008, (June30, 2008), our fiscal auditor will be contacted to schedule a date for our annual audit. THe audit and report will need to be completed within six months of the end of the fiscal year audited. Contact will be made by the Executive Director and the expectations and requirements of meeting the time frame will be reviewed and understood at that initial contact. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records and staff interview, the facility failed to conduct unannounced fire drills at least once a month. No fire drill was conducted for March 2008.
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Plan of Correction
By the third weekly staff meeting of each month, Director will review fire drill log with fire safety comittee. If a drill has not been conducted in that month, the Director will instruct fire safety committee that such a drill will be need to be conducted by end of month. By May 15, 2008, Director will again review with fire safety committee the necessity of monthly fire drills (other activities don't replace the need for these such as maintenance, fire safety review, etc.) |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document progress notes which include data, assessment and plans relative to treatment in seven of ten records reviewed, #1, 3, 4, 5, 7, 8 and 10. The assessment portion of progress notes included additional data rather than an assessment of the client.
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Plan of Correction
Director and Clinical Director will institute new case notes which were also reviewed by the state inspector during our licensure monitoring visit. These were found to be acceptable in terms of capturing data, assessment and plan format to ensure that assessment section, in particular, be addressed. These new case notes were instituted by staff as of May 1, 2008. Clinical Director will review for content at regularly scheduled clinical supervision meetings with each staff person. |
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 aftercare plans which include goals with time frames in one of two client records reviewed, #7. Goals were not individualized and were missing time frames.
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Plan of Correction
Director and Clinical Director have designed new AFtercare Plan forms which are set up to include spaces for individualized goals and time frames that must be filled in. Staff have been advised of the new form in staff meeting on April 23, 2008. Clinical Director will monitor compliance at regularly scheduled Clinical Supervision meetings with each staff monthly. |