INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 29, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Licensure Programs. 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) 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.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form prior to releasing information, in two out of seven records reviewed.
Client #1 was admitted on December 16, 2020 and was still active at the time of the inspection. There was no documentation of a consent form for the funding source.
Client #3 was admitted on November 13, 2020 and was still active at the time of the inspection. There was no documentation of a consent form for the funding source.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the Agency All Staff meeting on 05/11/2021, the Director and Clinical Supervisor provided retraining on the requirements for a valid consent to release information. Clinical staff will work to update client consents obtained during the pandemic with client signatures. Clients scheduling new intakes will be informed of the options for obtaining signatures for properly authorized releases of information. This will primarily be accomplished through scheduling of in-person intakes with the option of telehealth for future services, if the client wishes. For those clients who do not wish to be seen in the office, consent forms will be mailed or emailed for the client to complete and return to the office prior to the release of any PHI. |
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 the review of client records, the facility failed to document a completed consent to release information form in two out of seven records reviewed. The forms were marked "other" for purpose, without listing the additional purpose.
Client #1 was admitted on December 16, 2020 and was still active at the time of the inspection. The form was dated December 16, 2020 to a government agency.
Client #2 was admitted on December 1, 2020 and was still active at the time of the inspection. One form was dated February 4, 2021 to a counseling agency. A second form was dated February 8, 2021 to parole.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the Agency All Staff meeting on 05/11/2021, the Director and Clinical Supervisor provided retraining on the requirements for a valid consent to release information. Clinical staff were reminded of the need for releases of information to be completed thoroughly and accurately, reviewing the purpose and type of information to be released with the client before obtaining the client's signature. Monthly QI chart reviews by the Clinical Supervisor for Training and Quality Improvement will target this area for compliance with the POC. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in three out of seven records reviewed, as there were forms that did not have a client signature.
Client #1 was admitted on December 16, 2020 and was still active at the time of the inspection. Two consent forms dated December 16, 2020 were to probation and a government agency.
Client #3 was admitted on November 13, 2020 and was still active at the time of the inspection. Two consent forms dated November 13, 2020 were to probation and a family member.
Client #5 was admitted on February 17, 2021 and was still active at the time of the inspection. Three consent forms dated February 9, 2021 were to a funding source, a counseling agency and probation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the Agency All Staff meeting on 05/11/2021, the Director and Clinical Supervisor provided retraining on the requirements for a valid consent to release information. Clinical staff will work to update client consents obtained during the pandemic with client signatures. Clients scheduling new intakes will be informed of the options for obtaining signatures for properly authorized releases of information. This will primarily be accomplished through scheduling of in-person intakes with the option of telehealth for future services, if the client wishes. For those clients who do not wish to be seen in the office, consent forms will be mailed or emailed for the client to complete and return to the office prior to the release of any PHI. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of client records, the facility failed to document an emergency contact in one out of two buprenorphine records reviewed.
Client #6 was admitted on February 8, 2021 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Every individual seen for medical services of any kind will be required to identify their emergency contact and sign the accompanying release of information statement at the initial appointment. The MAT Coordinator will be responsible for obtaining this contact information and reviewing the release of information consent with the client. A new document that contains the Emergency Contact name, contact information and the client's signed consent to release information was created for this purpose. The form is printed on red paper for quick access in the patient file in the event of an emergency. For clients already in service, the MAT Coordinator began confirming and documenting emergency contact information as of 05/01/2021. Clients are informed that the document becomes part of their medical file, and that the consent may be revoked at any time. Clients will also be informed that, in the event of revoking the consent, they would need to designate an alternative person as their Emergency Contact. It will be the responsibility of the reception staff to inquire about any changes to emergency contact information as part of the check-in process at each office visit. The MAT Coordinator will also update ER Contact information and obtain an updated release with the annual review of the MAT Treatment Agreement. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document type and frequency of treatment and rehabilitation services in four out of seven records reviewed.
Client #1 was admitted on December 16, 2020 and was still active at the time of the inspection. A comprehensive treatment plan dated March 1, 2021 had a range of 1-4x/ month for counseling services.
Client #3 was admitted on November 13, 2020 and was still active at the time of the inspection. A treatment plan dated April 22, 20201 had a range of 2-4x/ month for counseling services.
Client #4 was admitted on January 18, 2021 and was still active at the time of the inspection. A treatment plan dated February 6, 2021 had a range of 2-4x/ month for counseling services.
Client #5 was admitted on February 17, 2021 and was still active at the time of the inspection. A comprehensive treatment plan dated March 17, 2021 had a range of 2-4x/ month for counseling services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the Agency All Staff meeting on 05/11/2021, the Director and Clinical Supervisor provided retraining on the requirements for treatment planning and review. Clinical staff were informed of the need for frequency of contact to indicate the minimum number of contacts per month recommended to the client as part of the treatment planning process. This topic was further reviewed in Group Supervision on 05/25/2021 to insure the clarity of requirements. Monthly QI chart reviews by the Clinical Supervisor for Training and Quality Improvement will target this area for compliance with the POC. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services in the individual treatment and rehabilitation plan in three out of seven records reviewed.
Client #1 was admitted on December 16, 2020 and was still active at the time of the inspection.
Client #2 was admitted on December 1, 2020 and was still active at the time of the inspection.
Client #3 was admitted on November 13, 2020 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the Agency All Staff meeting on 05/11/2021, the Director and Clinical Supervisor provided retraining on the requirements for assessment, treatment planning and review with regard to the definition of "support services". Clinical staff were informed of the need to explore with clients and identify/document those support services being accessed by the client. This topic was further addressed by the clinical team in Group Supervision on 05/25/2021. Counselors were encouraged to identify and address in the treatment plan support needs and/or barriers to accessing support services that might impact on client recovery. Monthly QI chart reviews by the Clinical Supervisor for Training and Quality Improvement and follow-up in Individual and Group Supervision will target this area for compliance with the POC. |