INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16, 2025 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 five applicable records. Staff #1 was hired in the position of Project Director on August 10, 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 #4 was hired in the position of Counselor on December 18, 2024 and was in this position at the time of review. The facility was unable to provide a written individual training plan for Staff #4. Staff #5 was hired in the position of Counselor on December 18, 2024 and was in this position at the time of review. The facility was unable to provide a written individual training plan for Staff #5. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the April 17, 2024 annual licensing inspection.
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Plan of Correction
Project Director will complete training plans for Staff #1, Staff #4, and Staff #5 by 6/2/2025. For the next year, Office Manager will review all yearly training plans for completion of all clinical staff regardless of hire date. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of staff records, the facility failed to ensure staff persons received a minimum of 6 hours of HIV/AIDS training within the first year of employment in one of three applicable records. Staff #2 was hired to the position of counselor on February 6, 2024 and was in this position at the time of review. Staff #2 was due to complete HIV/AIDS training no later than February 6, 2025. Staff #2 did not complete HIV/AIDS training as of the time of review.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Project Director is actively working with nurse practitioner to complete required training in house for all current staff by end of June and will complete this yearly for all staff to ensure compliance. |
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 provide an initial comprehensive treatment and rehabilitation plan in accordance with the facility policy and procedure in two of five applicable records.The project policy and procedure indicated an initial comprehensive treatment and rehabilitation plan be completed by the second individual session after admission.Client #1 was admitted to the outpatient level of care on January 8, 2025 and was active at the time of review. The second individual session for client #1 took place on January 21, 2025. The initial comprehensive treatment plan was not completed until February 3, 2025. Client #7 was admitted to the outpatient level of care on June 19, 2024 and was discharged September 30, 2024. The second individual session for client #7 took place on July 17, 2024. No initial comprehensive treatment plan was completed for client #7 during his time in treatment. These findings were reviewed with the facility staff during the licensing process.This is a repeat citation from the April 17, 2024 annual licensing inspection.
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Plan of Correction
Project Director will review all new clients in weekly clinical meeting to ensure compliance of initial comprehensive treatment plan by second session. Staff will be trained on this in weekly staff meeting and chart audits will be completed to assess compliance. |
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 three of four applicable records.Client #1 was admitted to the outpatient level of care on January 8, 2025 and was active at the time of review. Client #1 ' s treatment plan dated February 3, 2025 did not contain proposed type of support services. Client #2 was admitted to the outpatient level of care on November 26, 2024 and was active at the time of review. Client #2 ' s treatment plan dated February 11, 2025 did not contain proposed type of support services. Client #3 was admitted to the outpatient level of care on September 6, 2024 and was active at the time of review. Client #3 ' s treatment plan dated November 7, 2024 did not contain proposed type of support services. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the April 17, 2024 annual licensing inspection.
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Plan of Correction
Support Services and resource section has been added to treatment plan template and marked mandatory for completion. Staff will be trained in Weekly staff meeting. Chart audits will completed quarterly to assess for compliance. |
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 a review of client records, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in four of four applicable records.Client #1 was admitted to the outpatient level of care on January 8, 2025 and was active at the time of review. A treatment plan update was due no later than April 3, 2025. No treatment plan update had been completed as of the time of review. Client #2 was admitted to the outpatient level of care on November 26, 2024 and was active at the time of review. A treatment plan update was due no later than April 11, 2025. No treatment plan update had been completed as of the time of review. Client #3 was admitted to the outpatient level of care on September 6, 2024 and was active at the time of review. A treatment plan update was due no later than January 7, 2025; however it was not completed until January 21, 2025. Another treatment plan update was due no later than March 21, 2025. No further treatment plan updates were completed as of the time of review. Client #6 was admitted to the outpatient level of care on July 22, 2024 and was discharged on December 6, 2024. A treatment plan update was due no later than October 14, 2024. No treatment plan update had been completed prior to client ' s discharge. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the April 17, 2024 annual licensing inspection.
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Plan of Correction
Project Director will train staff in new procedure to set reminder's on each client chart to ensure when next treatment plan update is due. Project Director will complete chart audit one month from training to ensure compliance and will continue quarterly chart audits. |
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 in six of six applicable records. The facility policy and procedure indicates a case consultation to occur every ninety days during the first year of treatment. Client #1 was admitted to the outpatient level of care on January 8, 2025 and was active at the time of review. A case consultation was due to occur no later than April 8, 2025. No case consult was completed for client #1.Client #2 was admitted to the outpatient level of care on November 26, 2024 and was active at the time of review. A case consultation was due to occur no later than February 26, 2025. No case consult was completed for client #2.Client #3 was admitted to the outpatient level of care on September 6, 2024 and was active at the time of review. A case consultation was due to occur no later than December 6, 2024. No case consult was completed for client #3.Client #5 was admitted to the outpatient level of care on July 1, 2024 and was discharged on October 26, 2024. A case consultation was due to occur no later than October 1, 2024. No case consult was completed for client #5.Client #6 was admitted to the outpatient level of care on July 22, 2024 and was discharged on December 6, 2024. A case consultation was due to occur no later than October 22, 2024. No case consult was completed for client #6.Client #7 was admitted to the outpatient level of care on June 19, 2024 and was discharged on September 30, 2024. A case consultation was due to occur no later than September 19, 2024. No case consult was completed for client #7.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the April 17, 2024 annual licensing inspection.
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Plan of Correction
Case Consultations will be reviewed monthly in weekly clinical meeting and staff trained in documentation process that will happen in real time at time of clinical meeting. Project Director will review in quarterly chart audits. |
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 a review of client records, the facility failed to complete an aftercare plan in four of four records. Facility policy and procedure states an aftercare plan will be completed at the time of discharge for all clients. Client #4 was admitted to the outpatient level of care on December 18, 2024 and was discharged March 4, 2025. No aftercare plan was completed for client #4.Client #5 was admitted to the outpatient level of care on July 1, 2024 and was discharged October 26, 2024. No aftercare plan was completed for client #5.Client #6 was admitted to the outpatient level of care on July 22, 2024 and was discharged December 6, 2024. No aftercare plan was completed for client #6.Client #7 was admitted to the outpatient level of care on June 19, 2024 and was discharged on September 30, 2024. No aftercare plan was completed for client #7.This finding was reviewed with facility staff during the licensing process.This is a repeat citation from the April 17, 2024 annual licensing inspection.
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Plan of Correction
Project Director will train staff in new procedure to discuss upcoming successful discharges in weekly clinical meeting to identify upcoming discharges and ensure compliance of completion of aftercare plan at time of discharge. Will continue to be assessed for compliance in quarterly chart audits |
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 ensure there is a complete client record which includes follow-up information in three of three applicable records. Facility policy and procedure states follow-up information is to be acquired 7 days post discharge for clients who have been referred to another provider, and 90 days post discharge for all clients.Client #5 was admitted to the outpatient level of care on July 1, 2024 and was discharged October 26, 2024. Follow-up information was due no later than January 26, 2025. The client record did not contain any follow-up information at the time of review. Client #6 was admitted to the outpatient level of care on July 22, 2024 and was discharged December 6, 2024. Follow-up information was due no later than March 6, 2025. The client record did not contain any follow-up information at the time of review. Client #7 was admitted to the outpatient level of care on June 19, 2024 and was discharged September 30, 2024. Follow-up information was due no later than December 30, 2024. The client record did not contain any follow-up information at the time of review. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director added follow up survery to discharge letter that will be sent to all discharged clients at time of discharge summary completion. Project Director will update policy and procedure to identify new process. Staff will be trained in new process and completed surveys returned to facility will be uploaded to client chart. Project Director will completed an audit of all discharged clients, 60 days after implementation of new procedure to ensure compliance and additional trainings will completed based on audit results. |