INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 12, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Monroe County Counseling Services, 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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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill logs from November 2022 through September 2023, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately a new section was included in Fire Drill Log to document whether a fire alarm or smoke detector was set off. The Project Director and Building Management met with other tenants to discuss our 'Fire Drill" schedule in order to minimize and/or avoid any inconvenience and/or disruption to their business operations. The Project Director will personally be involved in all scheduled Fire Drills and Fire Drill Log recordkeeping.
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of the client records, the facility failed to ensure that a data collection and recordkeeping system was developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
The facility uses a combination of paper files and electronic documents stored on a computer. Upon review of the records requested for the licensing inspection, the facility staff was not able to efficiently retrieve the requested documents. Additionally, in reviewing closed client records, there were missing documents and the facility was unable to provide them due to their current data collection system.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Until the October 12, 2023 site inspection this project maintained its recordkeeping on two computers and paper files. After discussing our current data collection and recordkeeping system with DDAP licensing staff, the Project Director met with a Computer Systems Professional to set up a consolidated system. To this end, the Project Director will implement immediately a "Dropbox' system that provides a centralized place to securely store entire client records and easily manage data access. |
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 a review of client records, the facility failed to document that a comprehensive treatment plan was developed with the client in one out of five applicable records reviewed.
Client #4 was admitted on August 15, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on August 17, 2023; however, did not have written documentation it was developed with the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A review of Client #4 record (who was Successfully Discharged on October 17, 2023),contained an unsigned copy of the treatment plan that had been reviewed with Client on October 17. Nevertheless, the client had participated in the development of his treatment plan and had a copy although the counselor failed to obtain his signature on that date due to oversight. The Project Director will allow more time for review of treatment plans with clients in order to avoid oversight mistakes moving forward. |
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 provide a complete client record, which is to include follow-up information in one out of three discharged records reviewed.
Client #2 was admitted on June 16, 2023 and discharged on July 8, 2023. A follow up was due per the facility's policy and procedures manual at 60 days after discharge, September 8, 2023; however, the follow up did not occur until October 14, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A review of the entire Client #2 record and our Court/Client tracking system indicated that client had received a 90-day incarceration sentence on July 14, 2023 and so we adjusted our follow-up notice schedule accordingly but failed to document same on the Record of Service log.
Effective immediately all future follow-up notices will be documented in Record of Service Logs and newly implemented "Drop Box' Client Information System that will be carefully monitored by Project Director.
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