INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, McDermott Counseling, 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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709.22 (b) (2) LICENSURE Governing Body
§ 709.22. Governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(2) Identifying the project ' s purpose and philosophy directly related to drug and alcohol services.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to identify the project's purpose and philosophy directly related to drug and alcohol services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
McDermott Counseling will have a policy and procedure manual that identifies purpose and mission by 1/19/2024.Agency director will ensure documentation with annual review. |
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
Based on review of the facility ' s policy and procedure manual, the facility failed to provide documentation of the project director preparing, annually updating, and signing a written manual delineating project policies and procedures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will provide an annual report outlining current policy and procedures manual. The delineation of policy/procedures will be updated by 01/19/2024.The revised agency policy/procedure manual will provide documentation more congruent with revised evaluation/referral status. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to adopt a written plan for the coordination of client treatment and rehabilitation services which includes, written procedures for the management of treatment/rehabilitation services for clients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Agency director will develop a written plan for coordination and management of patient treatment services. Procedures will be completed by 01/19/2024 .Updated plan will be reviewed by director on an annual basis-to ensure quality care. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. To include a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
McDermott Counseling per 709.30 civil rights of patient rights will have a written policy on civil rights. Procedure will ensure patient understands their rights. Documentation will include patient acknowledged awareness of their civil rights. Agency director will review patient chart to ensure policy is implemented. |
709.91(a)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(1) Criteria for admission.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to provide a written plan providing for intake and admission which includes criteria for admission.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
McDermott Counseling is an intake and referral agency. Agency director will be responsible for implementing criteria for admission. criteria will be reviewed annually in policy and procedure manual. |
709.91(a)(2) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(2) Treatment methodology.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to provide a written plan providing for intake and admission which includes treatment methodology.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
McDermott Counseling will provide documentation outlining treatment methods utilized to determine level of care -for admission. Agency director will review annually in policy and procedure manual. Each patient will be given these criteria at admission. |
709.91(a)(3) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(3) Requirements for completion of treatment.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to provide a written plan providing for intake and admission which includes requirements for completion of treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
McDermott Counseling provides intake and admission services. Patients will be given a written plan outlining the requirements to complete treatment. Agency director will review individual plan with each patient. This plan will be updated annually in the facility policy and procedure manual by agency director. |
709.91(a)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to provide a written plan providing for intake and admission which includes involuntary discharge/termination criteria.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
McDermott Counseling agency director will implement an updated policy to address involuntary discharge and/or termination. Agency director will review the written plan annually to ensure each patient has acknowledged the procedures. This policy will be included with admission and intake guidelines. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display to the general public the hours of project operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
McDermott COUNSELING has designed a sign to be displayed outside office door. It will be weather proof with protection of porch roof. Sign will be visible from Canal Street for anyone seeking services. Hours of operation continue to be 8a to 8p Monday -Friday /Weekend hours available by appointment, Phone number included on sign. |
709.94(d) LICENSURE Project management services
709.94. Project management services.
(d) The project shall develop a written client aftercare policy.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to provide documentation of a written aftercare policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Mcdermott Counseling will provide documentation of an aftercare policy. The policy and procedure will be reviewed annually by agency director. The written plan will be presented to each patient at intake and admission. |