INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 25, 2022 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:
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Plan of Correction
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709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of the client records, the facility failed to document a completed consent to release information in one out of seven records reviewed, as there was a form that was missing required information.
Client #2 was admitted to the facility on December 3, 2021 and was still active at the time of the inspection. There was a consent to release information form, signed and dated on January 1, 2022 to an emergency contact, but the form did not include the purpose of the disclosure.
The finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
- Clinical Supervisors review of the initial inspection findings in Group Supervision on 04/26/22 along with discussion of immediate documentation changes needed to ensure compliance
- 05/24/22 ? Teaching and discussion in Group Supervision of DDAP regulations regarding the essential components of a completed consent to release information
- Plan for periodic, targeted review of charts submitted for MD signature to be conducted by Clinical Supervisor for Training and QI. Formal, monthly review of randomly selected charts to be implemented in FY22-23. Detailed plan and system for chart review rubric and procedures to be developed by Clinical Supervisor and Director on 06/21/22 and presented agency-wide in All Staff Meeting on 07/12/22. |
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 the client records, the facility failed to provide a complete client record, which is to include an aftercare plan in one out of two records reviewed.
Client #7 was admitted to the facility on January 14, 2022 and was discharged on March 4, 2022. The client record did not contain documentation of an aftercare plan.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
- Clinical Supervisors review of the initial inspection findings in Group Supervision on 04/26/22 along with discussion of immediate documentation changes needed to ensure compliance
- 05/24/22 ? Teaching and discussion in Group Supervision of DDAP regulations regarding the need for documentation of an aftercare plan in the case of completed treatment, as well as follow-up post-discharge
- Plan for periodic, targeted review of charts submitted for closing signature to be conducted by Clinical Supervisor for Training and QI. Formal, monthly review of randomly selected closed files to be implemented in FY22-23. Detailed plan and system for chart review rubric and procedures to be developed by Clinical Supervisor and Director on 06/21/22 and presented agency-wide in All Staff Meeting on 07/12/22. |
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 a review of the client records, the facility failed to provide a complete client record, which is to include follow up information in one out of one record reviewed.
Client #6 was admitted on December 21, 2021 and discharged on February 28, 2022. The client record did not contain documentation of a follow up.
The finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
- Clinical Supervisors review of the initial inspection findings in Group Supervision on 04/26/22 along with discussion of immediate documentation changes needed to ensure compliance
- 05/24/22 ? Teaching and discussion in Group Supervision of DDAP regulations regarding follow-up upon completion of or withdrawal from treatment; reviewed current aftercare survey formats and methods for ensuring documentation of follow-up
- Plan for periodic, targeted review of charts submitted for closing signature by Clinical Supervisor for Training and QI. Formal, monthly review of randomly selected closed files to be implemented in FY22-23. Detailed plan and system for chart review rubric and procedures to be developed by Clinical Supervisor and Director on 06/21/22 and presented agency-wide in All Staff Meeting on 07/12/22. |