INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 17, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mind Dojo LLC 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of staff records, the facility failed to ensure a written individual training plan was developed for each employee in three of three records. Staff #1 was hired in the position of Project Director on May 22, 2023 and was in this position at the time of review. The facility was unable to provide a written individual training plan for Staff #1. Staff #2 was hired in the position of Counselor on November 13, 2023 and was in this position at the time of review. The facility was unable to provide a written individual training plan for Staff #2. Staff #3 was hired in the position of Project Director on February 6, 2024 and was in this position at the time of review. The facility was unable to provide a written individual training plan for Staff #3. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Individualized action plans will be completed for staff member #1, #2, #3 and shared with them before 6/1/2024 and then will be completed at the stated policy time of January each continuous year following that. Policy was reviewed by Clinical Director and shared with newly appointed Operational Manager to ensure continued compliance. Operational Manager will ensure completion of individualized training plan through yearly audit of policy |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of administrative records and staff interview, the facility failed to conduct unannounced fire drills at least once a month. No fire drills were conducted at the facility between August 10, 2023 when the facility gained licensure through the time of inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drill form was updated by Clinical Director to reflect the need for Monthly unannounced fire drills, rather then yearly. It was reviewed to meet all regulations and first unannounced fire drill was completed on 4/29/2024 and will be completed at random monthly. Clinical Director will work directly with Operations Manager and Office Manager to ensure monthly fire drills are completed and will be audited monthly during office safety check at the end of each month. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that a client receiving care or treatment under section 7 of the act (71 P.S. 1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment in seven of seven records. Client #1 was admitted to intensive outpatient on February 22, 2024 and still active at the time of the inspection. Client #2 was admitted to outpatient on March 11, 2024 and still active at the time of the inspection. Client #3 was admitted to intensive outpatient on March 20, 2024 and still active at the time of the inspection. Client #4 was admitted to intensive outpatient on February 12, 2024 and still active at the time of the inspection. Client #5 was admitted to intensive outpatient on March 27, 2024 and discharged on April 11, 2024. Client #6 was admitted to outpatient on October 11, 2023 and discharged on March 11, 2024. Client #7 was admitted to intensive outpatient on March 11, 2024 and discharged on April 2, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will complete a new Client Rights form that will accurately reflect the client rights outlined within the Regulations. This new form will be completed by Clinical Director by 6/1/2024 and will be addressed in following staff meeting to inform staff of the documentation change. They will also be instructed to make sure all current clients sign new form in EMR. Clinical Director will do a audit of EMR by 6/26/2024 to ensure compliance and will have all active clients sign corrected form by 7/1/2024 |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that the project may not discriminate in the provision of services on the basis of ethnicity and marital status in seven of seven records. Client #1 was admitted to intensive outpatient on February 22, 2024 and still active at the time of the inspection. Client #2 was admitted to outpatient on March 11, 2024 and still active at the time of the inspection. Client #3 was admitted to intensive outpatient on March 20, 2024 and still active at the time of the inspection. Client #4 was admitted to intensive outpatient on February 12, 2024 and still active at the time of the inspection. Client #5 was admitted to intensive outpatient on March 27, 2024 and discharged on April 11, 2024. Client #6 was admitted to outpatient on October 11, 2023 and discharged on March 11, 2024. Client #7 was admitted to intensive outpatient on March 11, 2024 and discharged on April 2, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will create a new Client Rights form that will accurately reflect the client rights to acknowledge right to not be discriminated against as outlined within the Regulations. This new form will be completed by Clinical Director by 6/1/2024 and will be addressed in following staff meeting to inform staff of the documentation change. They will also be instructed to make sure all current clients sign new form in EMR. Clinical Director will do a audit of EMR by 6/26/2024 to ensure compliance and will have all active clients sign corrected form by 7/1/2024
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that clients have the right to inspect their own records in seven of seven records. Client #1 was admitted to intensive outpatient on February 22, 2024 and still active at the time of the inspection. Client #2 was admitted to outpatient on March 11, 2024 and still active at the time of the inspection. Client #3 was admitted to intensive outpatient on March 20, 2024 and still active at the time of the inspection. Client #4 was admitted to intensive outpatient on February 12, 2024 and still active at the time of the inspection. Client #5 was admitted to intensive outpatient on March 27, 2024 and discharged on April 11, 2024. Client #6 was admitted to outpatient on October 11, 2023 and discharged on March 11, 2024. Client #7 was admitted to intensive outpatient on March 11, 2024 and discharged on April 2, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will create a new Client Rights form that will accurately reflect the client rights to inspect their own records as outlined within the Regulations. This new form will be completed by Clinical Director by 6/1/2024 and will be addressed in following staff meeting to inform staff of the documentation change. They will also be instructed to make sure all current clients sign new form in EMR. Clinical Director will do a audit of EMR by 6/26/2024 to ensure compliance and will have all active clients sign corrected form by 7/1/2024
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that clients have the right to appeal a decision limiting access to their records to the director in seven of seven records. Client #1 was admitted to intensive outpatient on February 22, 2024 and still active at the time of the inspection. Client #2 was admitted to outpatient on March 11, 2024 and still active at the time of the inspection. Client #3 was admitted to intensive outpatient on March 20, 2024 and still active at the time of the inspection. Client #4 was admitted to intensive outpatient on February 12, 2024 and still active at the time of the inspection. Client #5 was admitted to intensive outpatient on March 27, 2024 and discharged on April 11, 2024. Client #6 was admitted to outpatient on October 11, 2023 and discharged on March 11, 2024. Client #7 was admitted to intensive outpatient on March 11, 2024 and discharged on April 2, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will create a new Client Rights form that will accurately reflect the client rights to appeal a decision limiting access to their records as reflected within the regulations. This new form will be completed by Clinical Director by 6/1/2024 and will be addressed in following staff meeting to inform staff of the documentation change. They will also be instructed to make sure all current clients sign new form in EMR. Clinical Director will do a audit of EMR by 6/26/2024 to ensure compliance and will have all active clients sign corrected form by 7/1/2024
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in seven of seven records. Client #1 was admitted to intensive outpatient on February 22, 2024 and still active at the time of the inspection. Client #2 was admitted to outpatient on March 11, 2024 and still active at the time of the inspection. Client #3 was admitted to intensive outpatient on March 20, 2024 and still active at the time of the inspection. Client #4 was admitted to intensive outpatient on February 12, 2024 and still active at the time of the inspection. Client #5 was admitted to intensive outpatient on March 27, 2024 and discharged on April 11, 2024. Client #6 was admitted to outpatient on October 11, 2023 and discharged on March 11, 2024. Client #7 was admitted to intensive outpatient on March 11, 2024 and discharged on April 2, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will create a new Client Rights form that will accurately reflect the client rights to request the correction of inaccurate, irrelevant, outdated or incomplete records as outlined within the Regulations. This new form will be completed by Clinical Director by 6/1/2024 and will be addressed in following staff meeting to inform staff of the documentation change. They will also be instructed to make sure all current clients sign new form in EMR. Clinical Director will do a audit of EMR by 6/26/2024 to ensure compliance and will have all active clients sign corrected form by 7/1/2024
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that clients have the right to submit rebuttal data or memoranda to their own records in seven of seven records. Client #1 was admitted to intensive outpatient on February 22, 2024 and still active at the time of the inspection. Client #2 was admitted to outpatient on March 11, 2024 and still active at the time of the inspection. Client #3 was admitted to intensive outpatient on March 20, 2024 and still active at the time of the inspection. Client #4 was admitted to intensive outpatient on February 12, 2024 and still active at the time of the inspection. Client #5 was admitted to intensive outpatient on March 27, 2024 and discharged on April 11, 2024. Client #6 was admitted to outpatient on October 11, 2023 and discharged on March 11, 2024. Client #7 was admitted to intensive outpatient on March 11, 2024 and discharged on April 2, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will create a new Client Rights form that will accurately reflect the client rights to submit rebuttal data or memoranda to their own records as outlined within the Regulations. This new form will be completed by Clinical Director by 6/1/2024 and will be addressed in following staff meeting to inform staff of the documentation change. They will also be instructed to make sure all current clients sign new form in EMR. Clinical Director will do a audit of EMR by 6/26/2024 to ensure compliance and will have all active clients sign corrected form by 7/1/2024.
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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on applicable client records reviewed, the facility failed to document the disclosure to the client of criteria for admission, treatment, completion, and discharge in seven of seven records reviewed.Client #1 was admitted to intensive outpatient on February 22, 2024 and still active at the time of the inspection. Client #2 was admitted to outpatient on March 11, 2024 and still active at the time of the inspection. Client #3 was admitted to intensive outpatient on March 20, 2024 and still active at the time of the inspection. Client #4 was admitted to intensive outpatient on February 12, 2024 and still active at the time of the inspection. Client #5 was admitted to intensive outpatient on March 27, 2024 and discharged on April 11, 2024. Client #6 was admitted to outpatient on October 11, 2023 and discharged on March 11, 2024. Client #7 was admitted to intensive outpatient on March 11, 2024 and discharged on April 2, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will create a treatment disclosure form that will accurately reflect criteria for admission, treatment, completion, and discharge criteria. This new form will be completed by Clinical Director by 6/1/2024 and will be addressed in following staff meeting to inform staff of the documentation change. They will also be instructed to make sure all current clients sign new form in EMR. Clinical Director will do a audit of EMR by 6/26/2024 to ensure compliance and will have all active clients sign corrected form by 7/1/2024 |
709.92(a) 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:
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Observations
Based on applicable client records reviewed, the facility failed to provide an initial comprehensive treatment and rehabilitation plan in accordance with the facility policy and procedure manualin one of two client records. The project policy and procedure manual indicated an initial comprehensive treatment and rehabilitation plan be completed within thirty days of the preliminary treatment plan.Client #4 was admitted to intensive outpatient on February 12, 2024 and still active at the time of the inspection. A preliminary treatment plan was completed on February 14, 2024. An initial comprehensive treatment plan was due no later than March 14, 2024, however this was not completed at the time of the inspection.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Director will update policy to reflect that individualized initial treatment plan will be completed within the intake process as part of the biopsychosocial assessment that is already in place. Clinical Director will also change policy to reflect that comprehensive individualized treatment plans will need to be completed by the second office visit with primary therapist in individual session. Once policy is completed, it will be shared with staff in staff meeting by Clinical Director and as part of the continued efforts of compliance, all clinical staff will under go a treatment plan training to review policy and best practices for both initial and comprehensive treatment plan before the date of 7/1/2024. To Ensure compliance, quarterly chart audits will be completed by Clinical Director |
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 a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on individual treatment plans in one of one records. Client #6 was admitted to outpatient on October 11, 2023 and discharged on March 11, 2024. The comprehensive treatment and rehabilitation plan was dated December 10, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will provide a training to all clinical staff regarding best practices of treatment planning. They will review any policy changes and will also be given training on completion of comprehensive treatment plans every 60 days from first comprehensive treatment plan done. This training will take place before 7/1/2024. Quarterly chart audits will be completed by Clinical Director to ensure continued compliance with treatment plan regulations. |
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 a review of client records, the facility failed to document the proposed type of support services on individual treatment plans in one of one records.Client #6 was admitted to outpatient on October 11, 2023 and discharged on March 11, 2024. The comprehensive treatment and rehabilitation plan was dated December 10, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will provide a training to all clinical staff regarding best practices of treatment planning. They will review any policy changes and will also be given training on the need to document support services for each client. This training will take place before 7/1/2024. Quarterly chart audits will be completed by Clinical Director to ensure continued compliance with treatment plan regulations. |
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.
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Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in one of one applicable records.Client #6 was admitted to outpatient on October 11, 2023 and discharged on March 11, 2024. A treatment and rehabilitation plan was developed on December 10, 2023. A treatment and rehabilitation plan update was due no later than February 10, 2024, but was not completed prior to discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will provide a training to all clinical staff regarding best practices of treatment planning. They will review any policy changes and will also be given training on completion of comprehensive treatment plans every 60 days from first comprehensive treatment plan done. This training will take place before 7/1/2024. Quarterly chart audits will be completed by Clinical Director to ensure continued compliance with treatment plan regulations. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in one of one applicable records. The facility policy and procedure manual indicate a case consultation to occur every ninety days during the first year of treatment. Client #6 was admitted to outpatient on October 11, 2023 and discharged on March 11, 2024. A case consultation was due to occur no later than January 11, 2024, but this was not completed prior to discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director explored barriers surrounding completion of case consultations with DDAP clients and recognized lack of structure in case consultations. In order to have a more structured approach to case consultations with client's the Clinical Director will update policy to make case consultations completed during comprehensive treatment plan reviews to increase consistency. This will be given as a training to all Clinical Staff before 7/1/2024 and quarterly chart audits will be completed by Clinical Director to ensure compliance. |
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 applicable client records reviewed, the facility failed to complete an aftercare plan in accordance with the facility policy and procedure manual in three of three records. The facility policy and procedure manual indicated an aftercare plan will be completed at the time of discharge for all discharging clients. Client #5 was admitted to intensive outpatient on March 27, 2024 and discharged on April 11, 2024. An aftercare plan was not completed at the time of the inspection.Client #6 was admitted to outpatient on October 11, 2023 and discharged on March 11, 2024. An aftercare plan was not completed at the time of the inspection.Client #7 was admitted to intensive outpatient on March 11, 2024 and discharged on April 2, 2024. An aftercare plan was not completed at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will update policy to reflect that aftercare plans will be completed for successfully discharged client's at time of discharge to reduce lack of aftercare plans related to discharges against medical advice. Once policy is updated, the Clinical Director will review policy changes with Staff and do a training in weekly staff meetings regarding aftercare plans for clients. Quarterly chart audits will be completed by Clinical Director to ensure compliance. |