INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on Janaury 14, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, McDermott Counseling 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) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's fire drill log from January 2019 until December 2019, the facility failed to conduct fire drills on different days and different times of the day as all twelve fire drills were conducted on the first of the month and at six am or ten pm.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
2020 fire drills will be conducted at intermittent intervals throughout the morning.afternoon.evenings and weekends.South Hanover fire company is one mile from office and can be accessed by 911. two exit doors are readily available on first floor.fire exinguisher is up to date with yearly inspection.
.no smoking permitted on property.fire alarms are working.patients are usually scheduled 8a to 8p.typical occupany is myself and patient. to date.since 2010 there hasbeen no fire.this plan is now in effect. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to include written procedures for the management of treatment/rehabilitation services for clients.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
effective date of corrective action.03/01/20 .Pamela McDermott.facility director will ensure the following written procedures.Upon admission to outpatient services/or initial session the psychosocial evaluation .medical assessment and initial treatment plan will be completed.The comprehensive treatment plan at the third session will be completed.Treatment plan update will be completed at two month interval.The discharge summary and aftercare plan will be completed at final session.A followup plan at 30 days post discharge to ensure the aftercare plan is being followed or if discharged patient requires additional service or referral . |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a discussion with facility director, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
McDERMOTT COUNSELING LLC is a solo practice.there is one owner.one therapist.one facility director.My understanding is the annual 2019 revenue does not meet criteria to warrant an independent audit.I would request exemption of this requirement. Baums tax service will continue to prepare quarterly statements and annual profit report.If an audit is required based on criteria other than financial-McDermott Counseling has not been informed-current profit/loss summary was provided on survey date 1/14/2020.If exemption of an audit is required -McDermott Counseling would request application or protocol for exemption. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a review of the policy and procedure manual and a discussion with facility staff, the facility failed to address the secure storage of client records stored on the "cloud".
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Pamela McDermott is only owner.therapist.serving as facility director-Pamela McDermott is only agency person.15 west canal street property is owned by Pamela McDermott- who has access to company property including all charts.The second floor and third floor of agency is where charts are stored that are closed. These would be paper /hard charts.records.files.My laptop and phone are on second floor during working hours -no one has access to second floor.One room is designed for storage.Charts are locked in chests.Door to room is locked. I am only person with key or aware of storage system.During working hours -I might have scheduled patients chart in my possession .The cloud of my electronic system is protected.Pamela McDermott is only person who can log in with password to retrieve a PDF. My phone is in sync and also password protected.This system has been in place since 2010. McDermott Counseling will create written policy including storage of charts and access to information-effective 3/01/2020 .Facility director is responsible for this corrective action. |
709.28 (c) 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.
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Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client records #3 and #6.
Client #3 had an eval completed on September 11, 2019. There was documentation that a report was sent to the Dept of Labor and Industry on December 14, 2019; however, there was no proper consent to release information form signed by the client prior to disclosure
Client #6 had an eval completed on July 12, 2019. There was documentation that a report was sent to an attorney's office on December 1, 2019; however, there was no proper consent to release information form signed by the client prior to disclosure.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Effective 3/01/2020.Pamela McDermott -facility director will ensure consent forms are signed completely as needed and placed in patients chart. Consent forms that meet department of health guidelines are available and accessible since 2010.
Plan of correction to be implemented by facility director will entail a check and balance system.When patient verbally requests release of information-written report-evaluation-or other clinical information.NO disclosure /release [ electronically or via mail] without facility director placing written consent.signed.in patients chart.
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709.30 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.
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Observations
Based on a review of client records, the facility failed to ensure that all client records contained written acknowledgement by clients that they have been notified of their client rights in two client records.
Client record #5 had an evaluation on June 19, 2019 failed to contain the signed acknowledgement.
Client Record #6 had an evaluation on July 12, 2019 failed to contain the signed acknowledgement
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
effective 3/01/2020 facility director Pamela McDermott will check all admission packets .Patient rights forms were developed 2010 by facility.The patient rights form is given to all patients at intake.Corrective action administered by facility director will include a review of admission packet prior to end of initial session/intake.Director will ensure patients acknowlegement with signature is visible on patients rights form. |
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
Based on a review of six client records, the facility failed to ensure that all client records contained a completed and signed consent to treatment.
Client record #5 had an evaluation on June 19, 2019 failed to contain the signed consent to treatment.
Client Record #6 had an evaluation on July 12, 2019 failed to contain the signed consent to treatment
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Effective 3/1/2020 -the facility director will review each chart at intake to ensure consent to treatment form is signed.The consent to treatment form was designed by McDermott Counseling 2010.It is given to every patient at intake.The form is included with admission packet.Consent to treatment is always discussed with new patient.Facility director will check signed signature prior to end of intake session as corrective action. |
709.44(a)(1)(i) LICENSURE Medical History
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of six client records, the facility failed to main client records that included medical history client records #1, #5 and #6.
Client Record #1 had an evaluation on October 1, 2019
Client Record #5 had an evaluation on June 19, 2019.
Client Record #6 had an evaluation on July 12, 2019.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Effective 3/1/2020 the facility director will review each patients chart at end of intake or initial session. McDermott Counseling designed and developed psychosocial evaluation packets in 2010. The packet includes medical history assessment.Prior to patients departure from intake or initial session -facility director will complete and review psychosocial evaluation with patient-including the medical history.Regardless of patient's eventual treatment modality-medical assessment will be included with psychosocial evaluation . |
709.44(a)(1)(ii) LICENSURE Drug/Alcohol history
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of six client records, the facility failed to main client records that included Drug or alcohol history or both in client records #1, #5 and #6.
Client Record #1 had an evaluation on October 1, 2019
Client Record #5 had an evaluation on June 19, 2019.
Client Record #6 had an evaluation on July 12, 2019.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Effective 03/01/2020 the facility director will review each chart at end of intake or initial session to ensure a substance use history is completed .McDermott Counseling designed and developed a substance use history as part of psychosocial evaluation in 2010.Regardless of patient's need for continued care determined per ASAM standards or mental health diagnosis per DSM-each chart will include substance use history.History will be included in each chart. |
709.44(a)(1)(iii) LICENSURE Personal history
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of six client records, the facility failed to main client records that included personal history in client records #1, #5 and #6.
Client Record #1 had an evaluation on October 1, 2019
Client Record #5 had an evaluation on June 19, 2019.
Client Record #6 had an evaluation on July 12, 2019.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Effective 03/01/2020 each patient chart will contain a personal history-completed by end of intake/initial session.Since 2010 the personal history has been included in psychosocial evaluation .Facility director will review that each chart has included and completed personal history as standard requirement in all charts;Regardless of patients determined treatment modality. |
709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
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Observations
Based on a review of six client records, the facility failed to main client records that included a psychosocial evaluation client records #1, #5 and #6.
Client Record #1 had an evaluation on October 1, 2019
Client Record #5 had an evaluation on June 19, 2019.
Client Record #6 had an evaluation on July 12, 2019.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Effective 03/01/2020 the facility director will review each chart by end of initial session/intake to determine a completed psychosocial evaluation is included in every chart.Since 2010 McDermott Counseling has developed and utilized a psychosocial evalation. Corrective action will include a completed psychosocial evaluation for every patient-regarless of treatment modality. |