INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 9, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, A. L. Mental Health Counseling PC 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) (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 conversation with staff, the facility failed to conduct unannounced fire drills from August 2022 through April 2023.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
705.28 (1) FIRE SAFETY
PREFIX TAG P273
A.L. MENTAL HEALTH COUNSELING PC WILL CONDUCT UNANNOUNCED FIRE DRILLS AT LEAST ONCE A MONTH UTILIZING THE FIRE DRILL LOG DEVELOPED BY THE PROJECT.
PERSON RESPONSIBLE TO CONDUCT FIRE DRILLS- THE PROJECT DIRECTOR, IS THE SOLE EMPLOYEE OF THE PROJECT, THEREFORE THEY WILL BE RESPONSIBLE TO CONDUCT THE FIRE DRILLS AND COMPLETE THE FIRE DRILL LOGS. A COMPUTER ALERT WILL BE SET TO REMIND THE PROJECT DIRECTOR OF THE NEED TO CONDUCT THE FIRE DRILL. ALL FIRE DRILL LOGS WILL BE MAINTAINED BY THE PROJECT DIRECTOR IN A SEPARATE FOLDER. IT SHOULD BE NOTED THAT ALL FIRE SAFETY RESPONSIBILITIES WILL BE ADDRESSED BY THE PROJECT DIRECTOR.( ANNUAL INSPECTIONS OF FIRE ALARMS AT PROJECT, EVALUATION OF OPERABILITY OF SMOKE ALARMS, ETC.)
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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 the review of client records, the facility failed to document type and frequency of treatment services on the client's individual treatment plan in one out of one record reviewed.
Client #1 was admitted on March 22, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was dated April 12, 2023.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.92 TREATMENT AND REHABILITATION SERVICES:
ID PREFIX TAG 1879
(a) A.L. MENTAL HEALTH COUNSELING PC WILL DEVELOP AN INDIVIDUAL TREATMENT AND REHABILITATION PLAN FOR ALL CLIENTS ADMITTED TO THE PROJECT. THE PLAN WILL INCLUDE, BUT NOT BE LIMITED TO, WRITTEN DOCUMENTATION OF:
(2.) TYPE AND FREQUENCY OF TREATMENT AND REHABILITATION SERVICES.
NOTE: THE COMPREHENSIVE TREATMENT PLAN ON CLIENT# 1, DATED APRIL 12, 2023, WILL BE UPDATED TO INCLUDE INDIVIDUAL COUNSELING (TYPE OF TREATMENT) AND THE FREQUENCY OF TREATMENT WILL BE UPDATED TO (WEEKLY COUNSELING). ADDITIONALLY, THE PROJECT WILL INSURE THAT TYPE AND FREQUENCY OF TREATMENT IS DOCUMENTED ON EACH FUTURE PATIENT.
ADDITIONALLY, THE TREATMENT AND REHABILITATION SERVICES PLAN WILL INCLUDE, BUT NOT BE LIMITED TO, WRITTEN DOCUMENTATION OF: NOTE: PLAN OF CORRECTION WILL BE IMMEDIATELY COMPLETED. (1) SHORT AND LONG TERM GOALS FOR TREATMENT AS FORMULATED BY BOTH STAFF AND CLIENT.
(2.) TYPE AND FREQUENCY OF TREATMENT AND REHABILITATION SERVICES.
709.92 (a) (3) PROPOSED TYPE OF SUPPORT SERVICES:
SUPPORT SERVICES WILL INCLUDE, BUT NOT BE LIMITED TO:
.HOUSING, FINANCIAL, FOOD, DENTAL, MEDICAL, VOCATIONAL, OCCUPATIONAL, EDUCATIONAL, 12 STEP REFERRAL, LEGAL, ETC.
NOTE: THE COUNSELOR WILL ASSIST THE CLIENT IN INSURING EFFECTIVE AND PROMPT LINKAGE WITH THE SUPPORT SERVICES/S. NOTE: PLAN OF CORRECTION WILL BE IMMEDIATELY COMPLETED.
(b) TREATMENT AND REHABILITATION PLANS WILL BE REVIEWED AND UPDATED AT LEAST EVERY (60) DAYS BY THE PROJECT.
(c) THE PROJECT WILL INSURE THAT THE COUNSELING SERVICES ARE PROVIDED ACCORDING TO THE INDIVIDUAL TREATMENT AND REHABILITATION PLAN.
(d) COUNSELING WILL BE PROVIDED TO A CLIENT ON A REGULAR AND SCHEDULED BASIS.
STAFF MEMBER RESPONSIBLE TO INSURE COMPLIANCE:
ALLA LEYBINSKY, PROJECT DIRECTOR HAS THE RESPONSIBILITY TO INSURE THAT THIS DEFICIENCY DOES NOT RECUR BY CLOSELY MONITORING ALL PATIENT FILES THAT ARE OPENED. SINCE ALLA LEYBINSKY IS CURRENTLY THE ONLY EMPLOYEE OF THE PROJECT, SHE WILL REVIEW ALL NEW CASES TO INSURE TYPE AND FREQUENCY OF TREATMENT IS COMPLETED. ADDITIONALLY, (1) THERE WILL BE A COMPUTER PROMPT/ALERT ESTABLISHED TO NOTIFY MS. LEYBINSKY OF THE COMPLETION OF THE TREATMENT AND REHABILITATION SERVICES FORM WITH EMPHASIS ON DOCUMENTATION OF TYPE AND FREQUENCY OF TREATMENT; (2) WRITTEN CHECKLIST WILL BE DEVELOPED TO BE UTILIZED AS A SYSTEM OF CHECKS AND BALANCES TO INSURE THAT ALL COMPONENTS OF THE TREATMENT AND REHABILITATION SERVICES ARE ADDRESSED AND COMPLETED ON EACH CLIENT.
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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 the review of client records, the facility failed to document proposed support services on the client's individual treatment plan in one out of one record reviewed.
Client #1 was admitted on March 22, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was dated April 12, 2023.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.92 TREATMENT AND REHABILITATION SERVICES:
ID PREFIX TAG 1879
(a) A.L. MENTAL HEALTH COUNSELING PC WILL DEVELOP AN INDIVIDUAL TREATMENT AND REHABILITATION PLAN FOR ALL CLIENTS ADMITTED TO THE PROJECT. THE PLAN WILL INCLUDE, BUT NOT BE LIMITED TO, WRITTEN DOCUMENTATION OF:
(2.) TYPE AND FREQUENCY OF TREATMENT AND REHABILITATION SERVICES.
NOTE: THE COMPREHENSIVE TREATMENT PLAN ON CLIENT# 1, DATED APRIL 12, 2023, WILL BE UPDATED TO INCLUDE INDIVIDUAL COUNSELING (TYPE OF TREATMENT) AND THE FREQUENCY OF TREATMENT WILL BE UPDATED TO (WEEKLY COUNSELING). ADDITIONALLY, THE PROJECT WILL INSURE THAT TYPE AND FREQUENCY OF TREATMENT IS DOCUMENTED ON EACH FUTURE PATIENT.
ADDITIONALLY, THE TREATMENT AND REHABILITATION SERVICES PLAN WILL INCLUDE, BUT NOT BE LIMITED TO, WRITTEN DOCUMENTATION OF: NOTE: PLAN OF CORRECTION WILL BE IMMEDIATELY COMPLETED. (1) SHORT AND LONG TERM GOALS FOR TREATMENT AS FORMULATED BY BOTH STAFF AND CLIENT.
(2.) TYPE AND FREQUENCY OF TREATMENT AND REHABILITATION SERVICES.
709.92 (a) (3) PROPOSED TYPE OF SUPPORT SERVICES:
SUPPORT SERVICES WILL INCLUDE, BUT NOT BE LIMITED TO:
.HOUSING, FINANCIAL, FOOD, DENTAL, MEDICAL, VOCATIONAL, OCCUPATIONAL, EDUCATIONAL, 12 STEP REFERRAL, LEGAL, ETC.
NOTE: THE COUNSELOR WILL ASSIST THE CLIENT IN INSURING EFFECTIVE AND PROMPT LINKAGE WITH THE SUPPORT SERVICES/S. NOTE: PLAN OF CORRECTION WILL BE IMMEDIATELY COMPLETED.
(b) TREATMENT AND REHABILITATION PLANS WILL BE REVIEWED AND UPDATED AT LEAST EVERY (60) DAYS BY THE PROJECT.
(c) THE PROJECT WILL INSURE THAT THE COUNSELING SERVICES ARE PROVIDED ACCORDING TO THE INDIVIDUAL TREATMENT AND REHABILITATION PLAN.
(d) COUNSELING WILL BE PROVIDED TO A CLIENT ON A REGULAR AND SCHEDULED BASIS.
STAFF MEMBER RESPONSIBLE TO INSURE COMPLIANCE:
THE PROJECT DIRECTOR HAS THE RESPONSIBILITY TO INSURE THAT THIS DEFICIENCY DOES NOT RECUR BY CLOSELY MONITORING ALL PATIENT FILES THAT ARE OPENED. SINCE THE PROJECT DIRECTOR IS CURRENTLY THE ONLY EMPLOYEE OF THE PROJECT, THEY WILL REVIEW ALL NEW CASES TO INSURE TYPE AND FREQUENCY OF TREATMENT IS COMPLETED. ADDITIONALLY, (1) THERE WILL BE A COMPUTER PROMPT/ALERT ESTABLISHED TO NOTIFY THE PROJECT DIRECTOR OF THE COMPLETION OF THE TREATMENT AND REHABILITATION SERVICES FORM WITH EMPHASIS ON DOCUMENTATION OF TYPE AND FREQUENCY OF TREATMENT; (2) WRITTEN CHECKLIST WILL BE DEVELOPED TO BE UTILIZED AS A SYSTEM OF CHECKS AND BALANCES TO INSURE THAT ALL COMPONENTS OF THE TREATMENT AND REHABILITATION SERVICES ARE ADDRESSED AND COMPLETED ON EACH CLIENT.
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