This report is a result of an on-site licensure renewal inspection conducted on March 26, 2024, 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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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 applicable records reviewed.
Client #3 was admitted on June 13, 2023, and was still active at the time of the inspection. A treatment plan update was completed on August 30, 2023, and the next update was due no later than October 30, 2023; however, the next update was completed on October 31, 2023. Additionally, a treatment plan update was completed on December 28, 2023, and the next update was due no later than February 28, 2024; however, the next update was completed February 29, 2024.
Client #4 was admitted on July 12, 2023, and was discharged on January 15, 2024. A comprehensive treatment plan was completed on August 9, 2023 and an update was due no later than October 9, 2023; however, it was completed on October 12, 2023.
Client #7 was admitted on August 10, 2023, and discharged on February 13, 2024. A treatment plan update was completed on November 6, 2023, and the next update was due no later than January 6, 2024; however, it was completed on January 11, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
- At the conclusion of the inspection, clarification was sought and received from DDAP Licensing Specialist regarding the timeframe calculation for treatment plan reviews and signature requirements for the Comprehensive Treatment Plan and Treatment Plan Reviews.
- Initial review of inspection findings in post-inspection Administration meeting on 03/26/24, along with discussion of potential procedural changes needed to ensure compliance.
- On 04/09/24 the Clinical Supervisor identified and reviewed deficiencies during an agency-wide staff meeting.
- During Clinical group supervision on 04/23/24, the standards for timely completion of treatment planning documents will be reviewed. All Clinical staff will be educated on the requirement to complete 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 05/01/24 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 on a reoccurring basis 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.
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