INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 8, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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
|
709.28 (c) (5) 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:
(5) Dated signature of witness.
|
Observations
Based on a review of seven client records, the project failed to 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 the dated signature of witness.
Client #2 was admitted on February 6, 2020 and was current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to probation was signed by the client but missing a dated signature of the witness.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Conducted a clinical staff team meeting where we reviewed this item and the definition/requirements for a valid consent. The Clinical Supervisor for Quality Assurance will begin in November 2020 to conduct monthly, random chart audits to ensure compliance with preparation of releases. Clinical staff were instructed to review new files upon receipt from the intake staff to ensure that all client and staff signatures have been obtained. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
|
Observations
Based on a review of seven client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the date, event or condition upon which the consent will expire.
Client #2 was admitted on February 6, 2020 and was current at the time of the inspection. On an informed and voluntary consent from the client for the disclosure of information contained in the client record the date, event or condition upon which the consent will expire was missing.
Client #6 was admitted on July 3, 2019 and was discharged on September 13, 2020. On an informed and voluntary consent from the client for the disclosure of information to parole contained in the client record the date, event or condition upon which the consent will expire was missing.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Conducted a clinical staff team meeting where we reviewed this item and the definition/requirements for a valid consent. The Clinical Supervisor for Quality Assurance will begin in November 2020 to conduct monthly, random chart audits to ensure compliance with preparation of releases. Clinical staff were instructed to review new files upon receipt from the intake staff to ensure that all client and staff signatures have been obtained. Additionally, general and frequently used blank releases (e.g., Probation, SCA) will be pre-populated with an expiration date of "90 days after discharge". |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
|
Observations
Based on a review of four client records, the program failed to verify that the individual had reached 18 years of age prior to administration of an agent.
Client #4 was admitted on December 12, 2019 and was current at the time of the inspection. The program failed to verify Client #4 had reached 18 years of age prior to administration of an agent.
Client #5 was admitted on September 26, 2018 and was discharged March 12, 2020. The program failed to verify Client #5 had reached 18 years of age prior to administration of an agent.
These findings were reviewed with the program staff during the licensing process.
|
Plan of Correction
At check-in ALL individuals presenting for an initial physician appointment must present a current Driver's License or Photo Identification that includes their name, DOB and address. Valid identification will be obtained and photocopied by the receptionist or LPN as part of the initial medical intake process, and the copy will be maintained in the patient file. If the patient does not have a driver's license or photo I.D., another approved form of identification (e.g., birth certificate, passport) will be obtained. If the form of identification obtained does not include a photo, a file photo will be obtained with the patient's consent and maintained in the file for medical staff verification of patient's identity at each visit. |
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.
|
Observations
Based on a review of four client records, the program failed to verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
Client #4 was admitted on December 12, 2019 and was current at the time of the inspection. The program failed to verify Client #4's identity including name, address and date of birth.
Client #5 was admitted on September 26, 2018 and was discharged March 12, 2020. The program failed to verify Client #5's identity including name, address and date of birth.
These findings were reviewed with the program staff during the licensing process.
|
Plan of Correction
At check-in ALL individuals presenting for an initial physician appointment must present a current Driver's License or Photo Identification that includes their name, DOB and address. Valid identification will be obtained and photocopied by the receptionist or LPN as part of the initial medical intake process, and the copy will be maintained in the patient file. If the patient does not have a driver's license or photo I.D., another approved form of identification (e.g., birth certificate, passport) will be obtained. If the form of identification obtained does not include a photo, a file photo will be obtained with the patient's consent and maintained in the file for medical staff verification of patient's identity at each visit. In addition, the name, address and phone number of an emergency contact will be identified and documented on a valid consent to release information, and the signed consent will be maintained in the patient file for medical staff reference and verification before administration of medication. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on a review of four client records the program failed to provide individualized psychotherapy services for each patient including an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy.
Client #1 was admitted on January 13, 2020 and was current at the time of the inspection. Client #1 started receiving Buprenorphine on September 2, 2020. Client #1 had 55 minutes of individual therapy in September 2020.
Client #4 was admitted on December 12, 2020 and was current at the time of the inspection. Client #4 started receiving Sublocade on September 2, 2020. Client #4 had 55 minutes of individual therapy in September 2020.
Client #5 was admitted on September 26, 2020 and was discharged on March 12, 2020. Client #5 had 75 minutes of individual therapy in November 2019 and 0 minutes of group therapy, 0 minutes of therapy in December 2019 and 2 hrs and 30 minutes of individual therapy in January 2020, but no group therapy.
These findings were reviewed with the program staff during the licensing process.
|
Plan of Correction
At the onset of treatment, patients will be required to review with the MAT Coordinator, and sign, a treatment agreement that outlines the counseling requirements for participation in the program. A copy of the treatment agreement will be given to the individual's counselor for reference and review with the client. On the 21st day of each month, a report indicating the number of completed counseling hours for individuals participating in the Buprenorphine program will be generated in QuickBooks by the Office Manager. This report will be reviewed by the MAT Coordinator, and an email or internal chat message will be sent to the individual's counselor if s/he is out of compliance or at risk of not completing required counseling hours within the given month. Following the close of each month a final report of completed counseling hours will be compiled by the Office Manager and given to the MAT Coordinator. The MAT Coordinator will contact the counselor of any individual who did not meet attendance compliance for the previous month. The individual's counselor will then be responsible for conducting a session within seven (7) days to develop and document a plan of correction with the individual that includes a plan for attendance, identifies/addresses attendance barriers, and ensures alignment with the individual's plan of care within the subsequent thirty-day period. The plan of correction for attendance compliance will be signed by both the counselor and individual, a copy will be obtained for the counseling file, and the original will be forwarded to the MAT Coordinator for physician review/signature. The original plan of correction will be maintained in the medical file.
|
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on the review of seven client records on October 8, 2020, the facility failed to review and update treatment and rehabilitation plans at least every 60 days.
Client #4 was admitted on December 12, 2019 and was current at the time of the inspection. Client #4 had a treatment plan update on December 30, 2019 and then should have had one no later than February 28, 2019 but did not have one until March 5, 2020. Another treatment plan update was due no later than May 5, 2020 but was not completed until July 28, 2020.
Client #5 was admitted on September 26, 2018 and was discharged on March 12, 2020. Client #5 had a treatment plan update on June 26, 2019 and the next should have been no later than August 26, 2019 but next update did not occur until January 24, 2020.
Client #6 was admitted on July 3, 2019 and was discharged on September 13, 2020. Client #6 had a treatment plan update on November 7, 2019 with the next due no later than January 7, 2020 but was completed on February 24, 2020. Another treatment plan update was completed on June 19, 2020 with the next due no later than August 19, 2020 but was not completed until August 28, 2020.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Conducted a clinical staff team meeting where we reviewed this item and the requirements for timely completion of treatment plan reviews. The Clinical Supervisor for Quality Assurance will begin in November 2020 to conduct monthly, random chart audits to ensure compliance with completion of treatment plan reviews. Clinical staff were instructed to utilize the chart tracking stickers, client roster document or other system to indicate the dates by which subsequent treatment plans are due. All clinical staff are notified of the Medical Director's hours and availability to review and sign treatment plan documents via monthly calendar produced by the Director. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
|
Observations
Based on a physical site inspection on October 8, 2020, the project failed to display conspicuously to the general public the hours of project operation.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Following the inspection exit interview, a document indicating the agency's hours of operation and an emergency contact number was created and printed by the Director. The information was then posted on the two public entrance doors of the building. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
|
Observations
Based on a physical site inspection on October 8, 2020, the project failed to display conspicuously to the general public a telephone number for emergency purposes.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Following the inspection exit interview, a document indicating the agency's hours of operation and an emergency contact number was created and printed by the Director. The information was then posted on the two public entrance doors of the building. |