INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mainstream Counseling, 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:
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Plan of Correction
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705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical site inspection, it was determined that the facility failed to ensure fire extinguishers were mounted to the wall.The fire extinguisher located near the second floor lavatory was not secured to a wall. This finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
- Initial review of inspection findings in post-inspection Administration meeting on 5/2/23, along with discussion of immediate resolution needed to ensure compliance.
- On 5/11/23, Liberty Fire Solutions came to program site and mounted the fire extinguisher to wall adjacent to second floor lavatory. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from April 2022 - April 2023, the facility failed to prepare alternative exit route to be used during fire drills, as all drills utilized the same exit routes. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
-Initial Review of inspection findings in post-inspection Administration meeting on 04/25/23, along with discussion of potential procedural changes needed to achieve compliance.
-5/18/23- Deputy Director and Fire Safety Coordinator met and reviewed the Fire Safety standards as outlined in DDAP regulations. Directly following the review, the program's written Fire Drill record was amended and a section was added, pertaining to alternative exit routes which may be used during fire drills. Documentation now requires director to ensure ongoing compliance.
-This new process will be implemented immediately and reviewed agency wide during the All Staff meeting on 6/13/23. |
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.
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Observations
Based on the review of client records, it was determined that the facility failed to properly complete consent forms in two out of seven client records reviewed. The incomplete consent forms omitted the purpose of the disclosure. Client #2 was admitted on June 15, 2022 and was still an active client at the time of the inspection. The facility completed a consent, dated August 23, 2022, for probation but failed to document the purpose of the disclosure. Client #5 was admitted on September 28, 2022 and was discharged on November 3, 2022. The facility completed a consent, dated August 23, 2022, for an emergency contact but failed to document the purpose of the disclosure. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
-On 05/17/23 and 05/23/23, the Clinical Supervisors and Deputy Director met to identify documentation and staff training needs to ensure compliance with standards for completion of releases.
-Frequently used release forms (SCA, Probation, and Children & Youth) were edited to include those agency's contact information and pre-populate fields indicating the typical purpose of disclosure.
- The updated releases and standards for proper completion of all parts of the consents to release information were reviewed at a five-hour in-house Documentation Workshop on 05/30/23. All clinical staff were educated on the need to properly identify the purpose of release and to complete all areas of the form, including specification if "Other" is checked in any area.
- Monitoring for compliance will occur monthly beginning 06/05/23 through the following means:
1) Clinical Supervisor for QI (with help of support staff) will complete an audit of two (2) randomly selected open files from each counselor to identify deficiencies and ensure compliance. A standard rubric for chart review will be utilized and returned to individual counselors with the files to ensure correction of identified deficiencies.
2) Clinical Supervisors and Director will meet monthly to review chart audit results, identify individual staff re-education needs and develop staff retraining plan, if indicated. |
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 a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in three out of seven client records reviewed. Client #1 was admitted on November 22, 2022 and was still active at the time of the inspection. The client's treatment plan updates on February 4, 2023 and March 29, 2023 noted the frequency of treatment as " 1-2 times a month. "Client #5 was admitted on September 28, 2022 and was discharged on November 3, 2022. A comprehensive treatment plan developed on November 19, 2022 noted the frequency of treatment as " 1-2 times a month. "Client #7 was admitted on December 6, 2022 and discharged on March 27, 2023. A comprehensive treatment plan developed on January 4, 2023 noted the frequency of treatment as " 1-2 times a month. "These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
-On 05/17/23 and 05/23/23, the Clinical Supervisors and Deputy Director met to identify documentation and staff training needs to ensure compliance with standards specifying type and frequency of treatment and rehabilitation services on treatment plans and treatment plan reviews.
-The "type of service" section of the Initial Treatment Plan was edited to include a prompt to identify the minimum recommended contacts per month rather than a range.
- The updated treatment planning forms and standards for proper identification of type and frequency of recommended services were reviewed at a five-hour in-house Documentation Workshop on 05/30/23. All clinical staff were educated on the need to specify the type(s) of service recommended and the minimum frequency of services in all treatment planning documentation.
- Monitoring for compliance will occur monthly beginning 06/05/23 through the following means:
1) Clinical Supervisor for QI (with help of support staff) will complete an audit of two (2) randomly selected open files from each counselor to identify deficiencies and ensure compliance. A standard rubric for chart review will be utilized and returned to individual counselors with the files to ensure correction of identified deficiencies.
2) Clinical Supervisors and Director will meet monthly to review chart audit results, identify individual staff re-education needs and develop staff retraining plan, if indicated. |
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 document treatment plan updates within the regulatory timeframe in three out of five client records reviewed.Client #2 was admitted on June 15, 2022 and was still active at the time of the inspection. The comprehensive treatment plan was completed on July 6, 2022. An updated treatment plan was due September 6, 2022; however, the next updated treatment plan was completed November 2, 2022. Additionally, an updated treatment plan was completed on December 9, 2022. An updated treatment plan was due February 9, 2023; however, the next updated treatment plan was completed February 22, 2023. Client #3 was admitted on August 11, 2022 and was still active at the time of the inspection. The comprehensive treatment plan was completed September 8, 2023. An updated treatment plan was due November 8, 2022; however, the next documented treatment plan update was November 17, 2022. Client #4 was admitted on May 24, 2022 and was still active at the time of the inspection. A treatment plan update was completed on January 9, 2023. An updated treatment plan was due March 9, 2023; however, the next documented treatment plan update was March 13, 2023. This finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
- Following inspection, clarification was sought and received from DDAP Licensing Specialists regarding the timeframe calculation for treatment plan reviews and signature requirements for the Comprehensive Treatment Plan and Treatment Plan Reviews.
- On 05/17/23 and 05/23/23, the Clinical Supervisors and Deputy Director met to identify documentation and staff training needs to ensure compliance with DDAP regulations on timely completion of all treatment planning documentation.
- The standards for timely completion of treatment planning documents were reviewed at a five-hour in-house Documentation Workshop on 05/30/23. All clinical staff were educated on the requirement to include the client in development of the Comprehensive Treatment Plan within thirty (30) days from the start of treatment, and to review the plan at least every sixty (60) days. Pertinent sections of the agency's Policy and Procedure manual were reviewed with and provided to staff to ensure clarity on the required timelines.
- Monitoring for compliance will occur monthly beginning 06/05/23 through the following means:
1) Clinical Supervisor for QI (with help of support staff) will complete an audit of two (2) randomly selected open files from each counselor to identify deficiencies and ensure compliance. A standard rubric for chart review will be utilized and returned to individual counselors with the files to ensure correction of identified deficiencies.
2) Clinical Supervisors and Director will meet monthly to review chart audit results, identify individual staff re-education needs and develop staff retraining plan, if indicated. |
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 a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in two out of six applicable records reviewed. The facility's policy and procedures manual states that the case consultation shall occur within the first 90 days of treatment. Client #4 was admitted on May 24, 2022 and was still active at the time of the inspection. There was one case consultation documented in the client record on September 9, 2022.Client #7 was admitted on admitted on December 6, 2022 and discharged on March 27, 2023. There was no documentation of a case consultation in this client's record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
- On 05/17/23 and 05/23/23, the Clinical Supervisors and Deputy Director met to identify documentation and staff training needs to ensure compliance with the agency's policy and procedures regarding timely completion of case consultation.
-The Initial Treatment Plan was edited to include a prompt to engage in and document case consultation at or before development of the Comprehensive Treatment Plan.
- The updated form and standards for timely completion of case consultation were reviewed at a five-hour in-house Documentation Workshop on 05/30/23. All clinical staff were educated on the type(s) of collaboration that constitute case consultation, and how to properly reflect such consultation in the client record.
- Monitoring for compliance will occur monthly beginning 06/05/23 through the following means:
1) Clinical Supervisor for QI (with help of support staff) will complete an audit of two (2) randomly selected open files from each counselor to identify deficiencies and ensure compliance. A standard rubric for chart review will be utilized and returned to individual counselors with the files to ensure correction of identified deficiencies.
2) Clinical Supervisors and Director will meet monthly to review chart audit results, identify individual staff re-education needs and develop staff retraining plan, if indicated. |
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 provide a complete client record, which is to include follow-up information in three of three applicable client records. Client #5 was admitted on September 28, 2022 and was discharged on November 3, 2022. There was no documentation in the client record to verify a follow-up had been attempted. Client #6 was admitted on August 10, 2022 and was discharged on October 25, 2022. There was no documentation in the client record to verify a follow-up had been attempted. Client #7 was admitted on December 6, 2022 and was discharged on March 27, 2023. There was no documentation in the client record to verify a follow-up had been attempted. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
-Initial review of inspection findings in post-inspection Administration meeting on 05/02/23, along with discussion of potential procedural changes needed to ensure compliance.
- On 05/17/23 the Clinical Supervisor, Deputy Director and Director met to develop a new procedure to ensure client discharge follow-up contact. Consistent with standing procedure for routine review of closed files by Clinical Supervisor for Quality Improvement (QI), all closed files will now go to that supervisor for audit prior to signing of the Closing Summary. Closed clinical files will then go to the Receptionist for follow-up contact/attempt and documentation on the Closing Summary before being filed for storage with closed files.
- Clinical staff were educated on this new procedure at a five-hour in-house Documentation Workshop on 05/30/23. Clinical staff will also be reminded to adhere to the standing timeline for closing files within 45 days after no contact and sending a closing letter.
- Monitoring for compliance will occur monthly beginning 06/05/23 through the following means:
1) Clinical Supervisor for QI (with help of support staff) will complete an audit of two (2) randomly selected closed files pulled from storage to identify deficiencies and ensure compliance.
2) Clinical Supervisors and Director will meet monthly to review chart audit results, identify individual staff re-education needs and develop staff retraining plan, if indicated. |