INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 28, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mainstream Cousneling 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:
|
Plan of Correction
|
709.28 (c) (3) 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:
(3) Purpose of disclosure.
|
Observations
Based on review of the client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client records that includes the purpose of disclosure in four of the seven client records reviewed.
Client #1 was admitted on June 28, 2019 and was an active client at the time of the inspection. A release of information form to probation, signed and dated on June 28, 2019 did not document the purpose of disclosure.
Client #2 was admitted on February 17, 2021 and was an active client at the time of the inspection. Two release of information forms to probation and one to a community organization signed and dated on February 17, 2021 did not document the purpose of the disclosure. One release of information form to an attorney signed and dated on March 18, 2021 did not document the purpose of the disclosure.
Client #3 was admitted on December 24, 2019 and was an active client at the time of the inspection. A release of information form to probation signed and dated on December 17, 2019 did not document the purpose of the disclosure.
Client #7 was admitted on November 12, 2020 and was discharged on January 12, 2021. Release of information forms to a government agency and probation dated and signed on November 5, 2020 did not document the purpose of the disclosure.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
In the Agency All Staff meeting on 05/11/2021, the Director and Clinical Supervisor provided retraining on the requirements for a valid consent to release information. Clinical staff were reminded of the need for releases of information to be completed thoroughly and accurately, reviewing the purpose and type of information to be released with the client before obtaining the client's signature. Monthly QI chart reviews by the Clinical Supervisor for Training and Quality Improvement will target this area for compliance with the POC. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
|
Observations
Based on review of personnel records, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that the project had an unusual incident occur which involved a current client who died of natural causes. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
In the Agency All Staff meeting on 05/11/2021, the Director and Clinical Supervisor provided retraining on the Agency policy related to Reporting of Unusual Incidents. Staff were reminded to forward completed Incident Reports to the Director, who is responsible for reporting to the BHMCO and/or DDAP. |
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.
|
Observations
Based on a review of client records, the facility failed to document type and frequency of treatment and rehabilitation services on the comprehensive treatment plan on six out of the six records reviewed. The records reflected a range of recommended treatment and not a specific frequency of recommended treatment.
Client #1 was admitted on June 28, 2019 and was a current client at the time of the inspection.
Client #2 was admitted on February 17, 2021 and was a current client at the time of the inspection.
Client #3 was admitted on December 24, 2019 and was discharged on December 18, 2020.
Client #5 was admitted on March 29, 2019 and was a current client at the time of inspection.
Client #6 was admitted on July 10, 2020 and was a current client at the time of inspection
Client #7 was admitted on November 12, 2020 and discharged on January 12, 2021.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
In the Agency All Staff meeting on 05/11/2021, the Director and Clinical Supervisor provided retraining on the requirements for treatment planning and review. Clinical staff were informed of the need for frequency of contact to indicate the minimum number of contacts per month recommended to the client as part of the treatment planning process. This topic was further reviewed in Group Supervision on 05/25/2021 to insure the clarity of requirements. Monthly QI chart reviews by the Clinical Supervisor for Training and Quality Improvement will target this area for compliance with the POC. |
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.
|
Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the treatment plans on four of the six records reviewed.
Client #1 was admitted on June 28, 2019 and was a current client at the time of the inspection.
Client #2 was admitted on February 17, 2021 and was a current client at the time of the inspection.
Client #3 was admitted on December 24, 2019 and was discharged on December 18, 2020
Client #6 was admitted on July 10, 2020 and was a current client at the time of inspection
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
In the Agency All Staff meeting on 05/11/2021, the Director and Clinical Supervisor provided retraining on the requirements for assessment, treatment planning and review with regard to the definition of "support services". Clinical staff were informed of the need to explore with clients and identify/document those support services being accessed by the client. This topic was further addressed by the clinical team in Group Supervision on 05/25/2021. Counselors were encouraged to identify and address in the treatment plan support needs and/or barriers to accessing support services that might impact on client recovery. Monthly QI chart reviews by the Clinical Supervisor for Training and Quality Improvement and follow-up in Individual and Group Supervision will target this area for compliance with the POC. |