INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on April 24, 2019, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site investigation, Mainstream Counseling, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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
During a review of seven client records, the facility failed to provide documentation that individual treatment and rehabilitation plans were developed with the client.
Client #7 was admitted on October 11, 2018 and discharged on January 31, 2019. The client 's comprehensive treatment plan dated November 1, 2018 was not signed by the client. The treatment plan update dated January 1, 2019 was not signed by the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
At the onsite inspection conducted on 4/24/2019, the clinical supervisor acknowledged and confirmed that she was the clinician responsible for client #7, and that the comprehensive treatment plan update dated 1/1/2019 were not signed by the client.
In an administrative meeting on 5/14/2019 this oversight was discussed and it was decided that the clinical supervisor will review in a group supervision meeting on 6/12/2019, the importance of timely client signatures on treatment plans. For ongoing compliance regarding this issue, beginning 7/1/2019, our quality assurance team will review 3 client charts from each therapist a month. The quality assurance supervisor will report findings monthly during administrative team meeting.
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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
During an onsite annual licensure inspection on April 24, 2019, fourteen months of facility fire drill records were reviewed. The facility failed to conduct unannounced fire drills at least once a month.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
At the onsite inspection conducted on 4/24/2019 the fire safety committee representative confirmed that the facility failed to conduct unannounced fire safety drills at least once per month. The fire safety committee designee and the Director met and decided the following plan:
By the 3rd weekly staff meeting on 5/21/2019, the Director will review fire drill log with fire safety committee designee and instruct that an unannounced fire drill for May 2019 will need to be done before May 31,2019. There will be at least one unannounced fire drill conducted each month by the fire safety committee representative. If an unannounced drill has not been conducted by the 3rd week of each month, the director will at that time instruct the fire safety committee designee, that such a drill will need to be conducted before the end of the month. Director will review fire safety log for accuracy monthly to ensure accurate accounting of such drills have occurred.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
During an onsite annual licensure inspection conducted on April 24, 2019, the Project Director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As the result of an onsite annual licensure inspection conducted on 4/24/2019 finding, the Project Director acknowledges failure to sign the update of the written manual delineating policies and procedures. Because this was the first year of the agency having a second site this detail was overlooked. During an adhoc Board of Directors meeting on 6/6/2019 the Project Director presented the procedure manual to the board for review. Beginning 7/1/2019 and there-after, the Project Director will be asked to present to the Board of Directors proof of an updated and signed policy and procedure manual by the 1st quarterly meeting on the Board of Directors which takes place each year in September. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
During an onsite annual licensure inspection, on April 24, 2019, the project director failed to develop a comprehensive staff development program that included a mechanism to collect feedback on completed training.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As the result of an onsite annual inspection conducted on 4/24/2019 finding, the Clinical Supervisor acknowledges failure to develop a comprehensive staff development program that included a mechanism to collect feedback on completed training. In order to ensure compliance, the Director and Clinical Supervisor have decided that each monthly group beginning 6/11/2019; will incorporate a standard agenda item of review any staff trainings attended. This information will be documented in a log book maintained by the clinical supervisor. Facility Director will affirm adherence to this standard at each monthly administrative meeting by asking to review the training log. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
During an onsite annual licensure inspection, on April 24, 2019, the project director failed to develop a comprehensive staff development program that included an annual evaluation of the overall training plan.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As the result of an onsite annual inspection conducted on 4/24/2019 finding, the Clinical Supervisor acknowledges failure to develop a comprehensive staff development program that included and annual evaluation of the overall training plan.
The Facility Director and Clinical Supervisor have met and decided that as a yearly agenda item to be discussed at the first administrative meeting following the end of the fiscal year (6/30/19), the Clinical Supervisor will present a compilation of the previous fiscal year's overall staff trainings for the administrative team to review and also to provide feedback regarding suggestions for the following fiscal year which begins 7/1/2019. The Director and Clinical Supervisor will ensure this is a yearly agenda item for the administrative meeting to be reviewed.
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