INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16-19, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Summit BHC Westfield, LLC d/b/a Mountain Laurel Recovery Center, was found to be not 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
The facility failed to document that all employees received an individual training plan annually. No training plans for the current year were documented for the following employees.Employee #8 was hired as medical doctor on 9/10/15. Employee #9 was hired as medical doctor on 11/17/15.Employee #10 was hired as medical doctor on 4/26/17.Employee #11 was hired as a Physician ' s assistant on 12/1/16.This information was reviewed with the facility staff during the licensing inspection.This is a repeat citation from the last licensing inspection dated 10/20/17.
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Plan of Correction
MLRC will ensure compliance with all required documented elements of employee personnel files via program dashboard reports and HR file audits. The HR program Dashboard is completed on a monthly basis. The audits will be completed Monthly and reported on Quarterly at the Quarterly Quality Meeting ("Committee of the Whole"). The dashboard indictors track annual required training, worker compensation, recruitment, staff turnover, staff evaluation, orientation, and licensure verification / renewal of all employees. The Training Coordinator will ensure that all employees receive written individual training plans that are developed annually with input from the employee and the supervisor. The HR Manager will ensure all employee training plans are up to date and in the employees file. |
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
The facility failed to document that all employees completed the required HIV/AIDs and TB/STD training within the required timeframe. Employee #1 was hired as a counselor on 7/2/17 and promoted to Project Director on 8/29/18. The HIV/AIDS and TB/STD trainings were due to be completed by 7/2/18 but were not documented at the time of the inspection.Employee #2 was hired as a counselor on 12/21/15 and promoted to clinical supervisor on 2/19/16. The HIV/AIDS and TB/STD trainings were due to be completed by 2/19/18 but were not documented at the time of the inspection.Employee #3 was hired as a counselor on 4/24/17. The HIV/AIDS and TB/STD trainings were due to be completed by 4/24/18 but were not documented at the time of the inspection.Employee #7 was hired as a case manager on 12/21/15 and promoted to a counselor assistant on 11/13/16. The HIV/AIDS and TB/STD trainings were due to be completed by 11/13/17 but were not documented at the time of the inspection.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will ensure compliance with all general training requirements. The training coordinator will schedule a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics trainings using a Department approved curriculum. The training coordinator will ensure that counselors and counselor assistants complete the training within the first year of employment and that all other staff persons complete it within the first 2 years of employment. The HR Manager will ensure that these trainings are completed and that documentation of the completion of these trainings are in the employees file. Tracking of the completion of this training will be completed by retention of sign-in rosters and documentation in Training Files. These files will be audited quarterly for accuracy and compliance. These findings will be reported on Quarterly at the Quarterly Quality Meeting ("Committee of the Whole"). Employee #2 and employee #7 are no longer employed with MLRC and documentation of these trainings are unable to be found. Employee #1 and employee #3 had completed these trainings in a timely manner, although documentation is unable to be found. So, employee #1 and employee #3 are scheduled to complete a department approved curriculum training for a minimum of 6 hours of HIV/AIDs and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics on 12/13 and 12/20. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
The facility failed to document that a counselor assistant received the required training hours.Employee #7 was hired as a counselor assistant on 11/13/16; only 34 of the required 40 training hours were documented at the time of the licensing inspection. Training year reviewed January 1, 2017 through December 31, 2017.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will ensure compliance with training requirements for counselor assistants, by having counselor assistants complete at least 40 clock hours of training in their first year and 30 clock hours annually thereafter. The training coordinator and clinical director will work with the counselor assistant to develop a written individual training plan that meets these requirements. The training coordinator and clinical director will ensure that the required clock hours of training are completed and documented. The HR Manager will ensure that the written individual training plans and documentation supporting completion of the training hours are in the employees file. Tracking of the completion of this training will be completed by retention of sign-in rosters or provided certificates of completion and documentation in Training Files. These files will be audited quarterly for accuracy and compliance. These findings will be reported on Quarterly at the Quarterly Quality Meeting ("Committee of the Whole"). |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
The facility failed to maintain one primary care staff member for every 7 clients in the detoxification activity.During the licensing inspection the nursing supervisor and the facility director confirmed that the staff members listed on the detox census page were also responsible for other duties outside of the detox unit during their shift.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will ensure primary care staff are designated specifically to the detoxification activity and during this designation not have other duties assigned. The facility maintains one primary care staff member availability per 7 detox residents as required, based on the definition of primary care staff (Primary care staff ? The group of individuals, including clinical supervisors, counselors, physicians, physician's assistants, psychologists, registered nurses and licensed practical nurses who provide primary care services and those individuals who are responsible for developing and implementing the treatment plan) from the Division of Drug and Alcohol Program Licensure Licensing Alert 3?02. The Director of Nursing and Clinical Director will ensure that staff are scheduled and designated to the detoxification activity and during this designation not have other duties assigned. The Clinical Director and the Director of Nursing will ensure that this is accomplished during the daily morning meeting when a person served for Detoxification Services is present at MLRC. Should one of the two be unable to be attendance of the meeting, communication will be sent via e-mail to the other, including the Project Director in this communication, so that this ratio has been established and met, or if not, what is being done to correct it. This staffing pattern will also be represented on Staff schedules. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
The facility failed to keep the grounds free from any danger to health and safety.The steps from the mansion building's main entrance had cracks and were broken at the edge, creating a trip hazard. Additionally, the rear exit steps from the mansion's building basement had a large piece missing presenting a trip hazard.The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will ensure that the residential facility grounds are clean, safe, sanitary and in good repair as well as free of hazards. The facilities manager will complete monthly checks of the interior and exterior of the facility to ensure compliance. The Facilities Manager will ensure that the completed checks will be submitted to the Project Director to be reviewed quarterly during the Quarterly Quality Meeting, "Committee of the Whole." The facility staff will assist in this process by completing internal work orders or reporting of facility issues to the facility manager, who will address the issues. The facilities manager has filled the large piece missing in on the basement steps from the mansion. The facilities manager has replaced broken or cracked front entrance steps and continues to monitor this and other areas to ensure the facility grounds are safe and free of hazards. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to document that all staff received the fire extinguisher training upon hire.Employee #6 was hired as a counselor on 5/21/18; the fire extinguisher training was not documented until 9/26/18.The finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will ensure all staff are instructed in the use of fire extinguishers upon employment. The training coordinator will ensure all new staff receive a new hire orientation which includes the fire safety training within 48 hours of hire, during their New Hire Orientation. During this period of time, newly hired staff will only participate in onboarding activities and training to prepare for their role at MLRC. Staff will begin to execute the duties of their role once their New Hire Orientation has been completed. The facilities manager or a designee will complete this training with all new hires within 48 hours and provide documentation that this has occurred. The HR Manager will ensure the documentation of the completion of this training is in the employees file. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to document that all staff were trained to perform tasks during emergencies.Employee #6 was hired as a counselor on 5/21/18; the training for assigned tasks during emergencies was not documented until 9/26/18.The finding was reviewed with the facility staff during the licensing inspection..
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Plan of Correction
Beginning 11/12/2018, MLRC will ensure all staff are instructed in the steps to follow, tasks to complete and how to complete them in the event of an emergency upon employment. The training coordinator will ensure all new staff receive a new hire orientation which includes the fire safety training within 48 hours of hire, during their New Hire Orientation. During this period of time, newly hired staff will only participate in onboarding activities and training to prepare for their role at MLRC. Staff will begin to execute the duties of their role once their New Hire Orientation has been completed. The facilities manager or a designee will complete this training with all new hires within 48 hours and provide documentation that this has occurred. The HR Manager will ensure the documentation of the completion of this training is in the employees file. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document the time of day a fire drill was conducted in the fire drill record for the following months April, May and June 2018.The finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC has ensured that the forms have been changed to denote the time of day that the drill occurred. All required and requested information will be available upon request for future surveys. The person conducting the drill will circle the time of day (A.M. or P.M.). These forms are logged, checked and verified by the Facilities Manager as they are completed. The Facilities Manager will ensure that the completed checks will be submitted to the Project Director to be reviewed quarterly during the Quarterly Quality Meeting, "Committee of the Whole." |
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
The facility failed to provide written procedures for the management of treatment and rehabilitation services for clients.The facility's policy and procedure manual did not contain written procedures for the following activitivies; partial hospitalization activity and outpatient activitys, despite possessing a license for these activities.This information was reviewed with the facility during the licensing inspection.
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Plan of Correction
MLRC has developed written policies and procedures for the management of treatment and rehabilitation services for the activities of partial hospitalization and outpatient services, which are in process of internal corporate compliance and governing body review and approval. This can be found evidenced in MLRC's Policy & Procedure: PS-001, PS-007, PS-011 and SA-002. The Governing Body and Project Director will ensure that these updated Policies and Procedures are implemented appropriately, disseminated to and reviewed by all appropriate staff persons in a timely fashion. The Project Director will review the Policy and Procedure Manual on an annual basis to ensure continued compliance.
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on the physical plant inspection, the facility failed to secure confidential client information.Client identifying information was left unsecured on the counselor's desk in office #6 in the mansion building.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will ensure that all confidential client information is secured. The training coordinator and supervisor will ensure all new hire staff are trained in the importance of confidentiality at MLRC and in the proper manner to secure confidential client information. The QI/Risk Management Coordinator will complete periodic checks to ensure staff are following proper procedures and report these findings at committee of the whole meetings. The training coordinator and supervisors will ensure staff are retrained or action plans are developed to address deficiencies in this area. All current staff have been reminded of the importance of securing confidential client information since the exit date of this survey. |
709.28 (c) 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.
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Observations
Ten rehabilitation client records were reviewed on October 18, 2018; the facility failed to document a valid consent to release in client record, #17. Client #17 was admitted on 7/19/18 and was discharged on 9/7/18. Ten consents to release forms; 5 to treatment providers, 2 to government agencies, 1 to an employer, 1 to a family member and 1 to the funding source all dated 7/18/18, did not contain the dated signature of the witness. Additionally, a consent to release, dated 7/18/18 was signed by the client but did not identify the person or agency to whom the information was to be released, the information to be disclosed or the purpose of the information. The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
To ensure this deficiency does not occur again, MLRC will ensure that at the time of admission, a person who is receiving services fully completes all required releases of information. These releases will be signed and dated by all appropriate parties as soon as the forms are completed by the person served. These files will be reviewed by the Admissions Director following the admission if occurring during the business hours of operation, or the following business day to ensure that they are completed accurately and in a timely fashion. Should a release be found to have not been completed in total or completed accurately, the Admissions Director will ensure that a new release of information is obtained immediately upon discovery and filled out completely and properly, ensuring that it is signed and dated by all required parties.
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
The facility failed to provide an accurate active and discharge list during the presubmission and during the licensing inspection, which created delays in the administrative review. This information was reviewed with the facility during the licensing inspection.
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Plan of Correction
MLRC will ensure data collection and record keeping systems allow for the efficient retrieval of data in order to determine the project's performance in relationship to its stated goals and objectives. MLRC utilizes a client roster for active clients, which will continue to be updated on a daily basis by the Admissions Director. MLRC utilizes Salesforce, which is able to accurately track discharges and a report can be ran instantly to gather this information. MLRC Admissions Director will run this report at the end of each month and have hard copy availability of this for staff to produce as well as the ability to run the report on any given day for an up to the day report. All requested and required information will be available upon request for future surveys. |
709.81(a)(1) LICENSURE Intake and admission
709.81. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
The facility failed to have a written plan in place which includes criteria for admission.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC has developed a written plan which includes criteria for admission for the activities of partial hospitalization and outpatient services, which are in process of internal corporate compliance and governing body review and approval. This can be found evidenced in MLRC's Policy & Procedure: SA-002. The Governing Body and Project Director will ensure that these updated Policies and Procedures are implemented appropriately, disseminated to and reviewed by all appropriate staff persons in a timely fashion. The Project Director will review the Policy and Procedure Manual on an annual basis to ensure continued compliance. |
709.81(a)(3) LICENSURE Intake and admission
709.81. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(3) Requirements for completion of treatment.
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Observations
The facility failed to document written plan which includes requirements for the completion of treatment.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC has developed a written plan which includes criteria for completion of treatment for the activities of partial hospitalization and outpatient services, which are in process of internal corporate compliance and governing body review and approval. This can be found evidenced in MLRC's Policy & Procedure: PS-007. The Governing Body and Project Director will ensure that these updated Policies and Procedures are implemented appropriately, disseminated to and reviewed by all appropriate staff persons in a timely fashion. The Project Director will review the Policy and Procedure Manual on an annual basis to ensure continued compliance. |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
The facility failed to display the hours of operation.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will develop and post signage at prominent and publicly accessible entrances to the building that dictate the hours of business, contact information and notice of how to reach the appropriate party(ies) for information on services provided. The Project Director will ensure that this task is completed and all information is verified to be accurate and updated as needed. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
The facility failed to display the emergency telephone number.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will develop and post signage at prominent and publicly accessible entrances to the building that dictate the hours of business, contact information, notice of how to reach the appropriate party(ies) for information on services provided and the phone number to call in the event of an emergency. The Project Director will ensure that this task is completed and all information is verified to be accurate and updated as needed. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Seven detoxification client records were reviewed on October 18, 2018. The facility failed to document a psychosocial evaluation that included the counselor's documented clinical evaluation statement and recommendations in records, #5-7. Psychosocial evaluation for client #5 was documented on 10/9/18Psychosocial evaluation for client #6 was documented on 9/21/18Psychosocial evaluation for client #7 was documented on 9/3/18This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will ensure that detoxification client psychosocial evaluations occur on each client and that they include the counselor's clinical evaluation statement and recommendations. MLRC clinicians met on 11/21 to review the requirement, as well as to discuss how to document an appropriate clinical evaluation and recommendations. MLRC Clinical Director will complete regular chart audits to determine that all clients have completed psychosocial evaluations that include the counselor's clinical evaluation statement and recommendations, as well as provide necessary training or follow up with clinicians as needed on their clinical documentation. These results will be submitted to the Project Director to be reviewed during the Quarterly Quality Meeting, "Committee of the Whole." The addition of the need for the completion of Psychosocial Evaluations has been included and can be found evidenced in MLRC's Policy & Procedure: SA-002. The Governing Body and Project Director will ensure that these updated Policies and Procedures are implemented appropriately, disseminated to and reviewed by all appropriate staff persons in a timely fashion. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Ten rehabilitation client records were reviewed on October 18, 2018. The facility failed to document a psychosocial evaluation that included the counselor's documented clinical evaluation statement and recommendations in records, #12 & 15-17. Psychosocial evaluation for client #12 was documented on 9/2/18Psychosocial evaluation for client #15 was documented on 8/10/18Psychosocial evaluation for client #16 was documented on 8/23/18Psychosocial evaluation for client #17 was documented on 7/18/18This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will ensure that client psychosocial evaluations occur on each client and that they include the counselor's clinical evaluation statement and recommendations. MLRC clinicians met on 11/21 to review the importance of this practice, as well as to discuss how to document an appropriate clinical evaluation and recommendations. To ensure that this deficiency does not occur again, MLRC Clinical Director will complete regular chart audits to determine that all clients have completed psychosocial evaluations that include the counselor's clinical evaluation statement and recommendations, as well as provide necessary training or follow up with clinicians as needed on their clinical documentation. These results will be submitted to the Project Director to be reviewed during the Quarterly Quality Meeting, "Committee of the Whole." The addition of the need for the completion of Psychosocial Evaluations has been included and can be found evidenced in MLRC's Policy & Procedure: SA-002. The Governing Body and Project Director will ensure that these updated Policies and Procedures are implemented appropriately, disseminated to and reviewed by all appropriate staff persons in a timely fashion. |
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
The facility failed to document a written plan which includes criteria for admission.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC has developed a written plan which includes criteria for admission for the activities of partial hospitalization and outpatient services, which are in process of internal corporate compliance and governing body review and approval. This can be found evidenced in MLRC's Policy & Procedure: SA-002. The Governing Body and Project Director will ensure that these updated Policies and Procedures are implemented appropriately, disseminated to and reviewed by all appropriate staff persons in a timely fashion. The Project Director will review the Policy and Procedure Manual on an annual basis to ensure continued compliance. |
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
The facility failed to document a written plan which includes requirements for the completion of treatment.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC has developed a written plan which includes criteria for the completion of treatment for the activities of partial hospitalization and outpatient services, which are in process of internal corporate compliance and governing body review and approval. This can be found evidenced in MLRC's Policy & Procedure: PS-007. The Governing Body and Project Director will ensure that these updated Policies and Procedures are implemented appropriately, disseminated to and reviewed by all appropriate staff persons in a timely fashion. The Project Director will review the Policy and Procedure Manual on an annual basis to ensure continued compliance. |
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
The facility failed to display the hours of operation.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will develop and post signage at prominent and publicly accessible entrances to the building that dictate the hours of business, contact information and notice of how to reach the appropriate party(ies) for information on services provided. The Project Director will ensure that this task is completed and all information is verified to be accurate and updated as needed. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
The facility failed to display an emergency telephone number.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will develop and post signage at prominent and publicly accessible entrances to the building that dictate the hours of business, contact information, notice of how to reach the appropriate party(ies) for information on services provided and the telephone number to call in the event of an emergency. The Project Director will ensure that this task is completed and all information is verified to be accurate and updated as needed. |
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
The facility failed to document a written client aftercare policy.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC has developed a written aftercare policy for the activities of partial hospitalization and outpatient services, which are in process of internal corporate compliance and governing body review and approval. This can be found evidenced in MLRC's Policy & Procedure: PS-007. The Governing Body and Project Director will ensure that these updated Policies and Procedures are implemented appropriately, disseminated to and reviewed by all appropriate staff persons in a timely fashion. The Project Director will review the Policy and Procedure Manual on an annual basis to ensure continued compliance. |
709.71(a)(1) LICENSURE Admission criteria
709.71. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
The facility failed to document a written plan which includes criteria for admission.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC has developed a written plan which includes criteria for admission to the transitional living program, which are in process of internal corporate compliance and governing body review and approval. This can be found evidenced in MLRC's Policy & Procedure: SA-002. The Governing Body and Project Director will ensure that these updated Policies and Procedures are implemented appropriately, disseminated to and reviewed by all appropriate staff persons in a timely fashion. The Project Director will review the Policy and Procedure Manual on an annual basis to ensure continued compliance. |
709.71(a)(2) LICENSURE Completion Guidelines
709.71. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(2) Guidelines for completion of residency.
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Observations
The facility failed to document a written plan which includes guidelines for the completion of residency.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC has developed a written plan which includes guidelines for the completion of residency in the transitional living program, which are in process of internal corporate compliance and governing body review and approval. This can be found evidenced in MLRC's Policy & Procedure: PS-007 and SA-002. The Governing Body and Project Director will ensure that these updated Policies and Procedures are implemented appropriately, disseminated to and reviewed by all appropriate staff persons in a timely fashion. The Project Director will review the Policy and Procedure Manual on an annual basis to ensure continued compliance. |
709.71(a)(3) LICENSURE Termination criteria
709.71. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(3) Involuntary discharge/termination criteria.
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Observations
The facility failed to document a written plan which includes criteria for involuntary discharge/termination.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC has developed a written plan which includes criteria for involuntary discharge/termination for the transitional living program, which are in process of internal corporate compliance and governing body review and approval. This can be found evidenced in MLRC's Policy & Procedure: PS-007. The Governing Body and Project Director will ensure that these updated Policies and Procedures are implemented appropriately, disseminated to and reviewed by all appropriate staff persons in a timely fashion. The Project Director will review the Policy and Procedure Manual on an annual basis to ensure continued compliance. |
709.73(a) LICENSURE Client Management Services
709.73. Client management services.
The transitional living facilities need not comply with 709.24 (a) (relating to treatment/rehabilitation management). The project's governing body shall instead adopt a written plan for the coordination of residential services which includes, but is not limited to:
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Observations
The facility failed to develop a written plan identifying the following:1. A defined target population2. A procedure for the management of residential services3. A procedure for referral with other service outlining cooperation with other providers.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC has developed a written plan which identifies a defined target population, procedure for the management of residential services and addresses referral and cooperation with other providers, which are in process of internal corporate compliance and governing body review and approval. This can be found evidenced in MLRC's Policy & Procedure: PS-001, PS-011 and SA-002. The Governing Body and Project Director will ensure that these updated Policies and Procedures are implemented appropriately, disseminated to and reviewed by all appropriate staff persons in a timely fashion. The Project Director will review the Policy and Procedure Manual on an annual basis to ensure continued compliance. |