INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 1, 2025, 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee #7 was hired as a counselor on September 22, 2021 and was still in the position as of the date of the inspection. The facility's training year that was reviewed was from July 1, 2023 through June 30, 2024. Employee # 7's record only documented 11 hours and 30 minutes of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
-Initial review of inspection findings in post-inspection meeting on 04/08/2025, along with discussion of potential procedural changes needed to ensure compliance.
-During Group Supervision on 4/08/2025, all Clinical staff were educated on the annual training hours requirement for the position of Counselor.
-On 4/09/2025, the Director met individually with the identified Clinician to review the deficiency. During the meeting the Director and Clinician reviewed the training regulations, including the completion of 25 training hours annually, as required for the position of Counselor.
- On 04/9/2025, the Administrative Clinical team met to identify a new procedure to ensure all Counselors meet their annual regulatory training requirements.
- Monitoring for compliance will begin 05/01/2025 through the following means:
1) Support staff will provide each individual Counselor a monthly update regarding the status of his/her training hours.
2) The Director will complete a quarterly review of all staff training to determine compliance. Any deficiencies will be noted and communicated.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility 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: specific information disclosed.
Client #1 was admitted on December 4, 2024, and was still active at the time of the inspection. Two release of information forms both signed on December 4, 2024, one for a payor and one for an emergency contact, did not include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
- At the conclusion of the inspection, clarification was sought and received from DDAP Licensing Specialist regarding release authorizations and the section of the consent regarding specific information to be disclosed.
- Initial review of inspection findings in post-inspection Administration meeting on 04/01/2025.
- On 4/02/2025, the Clinical Supervisors and Director met to identify documentation and staff training needs to ensure compliance with standards for completion of release authorization forms.
- During Group Supervision on 4/08/2025, all Clinical staff were educated on the need to complete all sections of the consent in full, to include properly identifying the specific information to be disclosed.
- Monitoring for compliance will occur monthly beginning 5/01/2025 through the following means:
1) Clinical Supervisor for QI (with help of support staff) will complete an audit of two (2) randomly selected open files from each counselor to identify deficiencies and ensure compliance. The Director will randomly audit two (2) of the Clinical Supervisor's files. A standard rubric for chart review will be utilized and returned to individual counselors with the files to ensure correction of identified deficiencies.
2) Clinical Supervisor and Director will meet monthly to review chart audit results, identify individual staff education needs and develop a staff retraining plan, if indicated.
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