INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20-21, 2013 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:
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Plan of Correction
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709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documentation and an interview with the facility director, the facility failed to document project goals and objectives for the 2012-2013 fiscal year.
The finding includes:
The annual onsite licensure renewal inspection was conducted on May 20-21, 2013. There was no documentation of the annual goals and objectives.
The finding was reviewed at the exit summary with the Project Director and was not disputed.
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Plan of Correction
At the on-site inspection conducted on May 20-21, 2013 the Facility Director acknowledged and confirmed that the Mainstream Counseling Project Goals and Objectives for the 2012-2013 Fiscal Year had been overlooked and not completed. A preliminary plan was drafted by the Facility Director and reviewed by the Project Director on June 10, 2013. The draft was approved, prepared and placed in the General Standards Manual by June 14, 2013. Because this document was retroactive it was not taken to the Board of Directors for approval. The Facility Director will develop a draft of Project Goals and Objectives for fiscal year 2013-2014 which will be completed by July 15, 2013. The Project Director will have two weeks to review the draft and make any changes/revisions; documentation will then be reviewed by the Board of Directors at the quarterly meeting held in August, 2013. Pending final approval by the Board the finalized document of Project Goals and Objectives for fiscal year 2013-2014 will be placed in the General Standards Manual by August 31, 2013. |
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 the facility policy and procedure manual and other administrative materials, the facility failed to document an annual audit for the fiscal year ended June 30, 2012.
The finding includes:
The annual onsite licensing renewal inspection was conducted on May 20-21, 2013. Administrative materials presented were reviewed on May 21, 2013. There was no documentation of an annual audit for the fiscal year ended June 30, 2012. An interview with the facility director confirmed that the audit had not been completed for the last fiscal year.
The finding was reviewed with the Project Director at the exit summary and was not disputed.
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Plan of Correction
At the on-site inspection conducted on May 20-21, 2013 it was confirmed by the Facility Director and Project Director that an annual audit had not been completed for fiscal year 2011-2012 due to financial constraints at Mainstream Counseling. Following this inspection, arrangements were made with our CPA to schedule the audit; she was on-site on Thursday, June 6 to begin the auditing process for fiscal year 2011-2012. At the time of this submission she has yet to complete the audit. As part of this audit the Facility Director requested that our CPA review Licensing Alert 01-11 to determine whether or not Mainstream Counseling would be eligible to file for an exception from the financial audit. If it is determined that we would qualify, the Facility Director will prepare the necessary documentation to submit to the Pennsylvania Department of Health requesting the exception. If it is determined that we do not qualify we will then make provisions to schedule our audit for fiscal year 2012-2013, with the goal of having it completed by December 31, 2013. Upon completion of the current fiscal audit copies will be on file and available to the public.
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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 client records, the facility failed to document follow up attempts in 3 of 4 client records in accordance with documented facility policy.
The finding includes:
The annual onsite licensure renewal inspection was conducted on May 20-21, 2013. Ten client records were reviewed. Four closed client records were required to include documentation of at least one attempt to follow up with the client. Documented facility policy states that follow up will be documented at 30 days for successful and administrative discharges and transfers to another program and at seven days for clients referred elsewhere for services.
Client record # 4 - This client was admitted on 1/18/13 and discharged on 4/4/13. No documentation of a follow up attempt was documented in the record at the time of the inspection.
Client record # 7 - This client was admitted on 10/18/11 and discharged on 12/18/12. No documentation of a follow up attempt was documented in the record at the time of the inspection.
Client record # 8 - This client was admitted on 6/20/12 and discharged on 4/30/13 . No documentation of a follow up attempt was documented in the record at the time of the inspection.
The findings were reviewed with the Project and facility directors and Clinical Supervisor at the exit summary and were not disputed.
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Plan of Correction
Facility Director and Clinical Supervisor met to develop a Plan of Correction addressing the citation pertaining to Follow-up information in the client records. A new procedure will be implemented immediately. This procedure is as follows: at the time of client discharge from treatment the counselor will submit a blue discharge form to the receptionist. (This is already being done). A satisfaction survey will now be placed in an addressed envelope to the client and will be submitted with the blue discharge document. The counselor will date the envelope so the receptionist will know when to mail the survey. When the receptionist mails the survey she will complete a receipt indicating the date the follow-up survey was mailed and return the receipt to the assigned counselor. The counselor will then file the receipt in the client chart to assure documentation that the follow-up has been completed. This procedure will occur for every closed client file within thirty (30) days of discharge whether discharge is considered successful, non-compliant, a transfer to other services, relocation or incarceration. The Clinical Director will revise the client discharge procedure documentation which will be reviewed by the Board of Directors at the quarterly meeting in August. Pending final approval the revision will be placed in the Outpatient Standards Manual by August 31, 2013. |