INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 21-22, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
|
Plan of Correction
|
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of fire drill logs from April 2022 - April 2023, the facility failed to prepare alternative exit route to be used during fire drills, as all drills utilized the same exit routes. This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
-Initial Review of inspection findings in post-inspection Administration meeting on 04/25/23, along with discussion of potential procedural changes needed to achieve compliance.
-5/18/23- Deputy Director and Fire Safety Coordinator met and reviewed the Fire Safety standards as outlined in DDAP regulations. Directly following the review, the program's written Fire Drill record was amended and a section was added, pertaining to alternative exit routes which may be used during fire drills. Documentation now requires director to ensure ongoing compliance.
-This new process will be implemented immediately and reviewed agency wide during the All Staff meeting on 6/13/23. |
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.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one of one applicable client record. Client #6 was admitted on August 18, 2022 and was discharged on November 11, 2022. This is a repeat citation from the April 25, 2022 licensing inspection. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
-Initial review of inspection findings in post-inspection Administration meeting on 04/25/23, along with discussion of potential procedural changes needed to ensure compliance.
- On 05/17/23 the Clinical Supervisor, Deputy Director and Director met to develop a new procedure to ensure client discharge follow-up contact. Consistent with standing procedure for routine review of closed files by Clinical Supervisor for Quality Improvement (QI), all closed files will now go to that supervisor for audit prior to signing of the Closing Summary. Closed clinical files will then go to the Receptionist for follow-up contact/attempt and documentation on the Closing Summary before being filed for storage with closed files.
- Clinical staff will be educated on this new procedure at a Documentation Workshop scheduled 05/30/23. Clinical staff will also be reminded to adhere to the standing timeline for closing files within 45 days after no contact and sending a closing letter. |