INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 8, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mazzitti and Sullivan Counseling Services, 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
The staffing requirements facility summary reports were reviewed on June 6, 2016. It was determined that the facility had 9 FTE counselors for the project and no full time clinical supervisor. The facility failed to employee one full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Plan of Correction
A new Mazzitti & Sullivan leadership model was established since the Pyramid Healthcare acquisition. As of July 1st, 2016 a Regional Director of Outpatient Services and 2 Clinical Directors were appointed to oversee the project. Ongoing oversight of Mazzitti & Sullivan Human Resources operations will fall under the direction of Pyramid Healthcare. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Six personnel records were reviewed on June 6, 2016. Six personnel records were required to include documentation of the qualifications for the position of counselor. The facility failed to provide documentation to verify the counselor's qualifications in personnel record # 6.
Employee # 6 was hired as counselor on August 5, 2015. The facility failed to document employee #6's qualifications.
The human resource staff was interviewed on June 6, 2016 and confirmed the findings
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Plan of Correction
Mazzitti & Sullivan will ensure that all staff adhere to the DDAP training requirements in order to meet the qualifications of counselor. Human Resources has or is in the process of obtaining the outstanding documentation and will complete this by 8/15/16. Ongoing oversight of Mazzitti & Sullivan Human Resources operations will fall under the direction of Pyramid Healthcare. |
704.11(f)(1) LICENSURE Counselor's Trng Req
704.11. Staff development program.
(f) Training requirements for counselors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
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Observations
Six personnel records were reviewed on June 6, 2016. Three out of six personnel records pertained to counselors and were reviewed for annual training hours. The facility's training year is from January through December. The facility failed to document 25 clock hours of annual training for employee #s, 4 and 5 for the January 1, 2015 - December 31, 2015 training year.
Employee # 4, a counselor, was hired in April of 2014. Employee record #4 contained documentation of 4 clock hours of annual training for the January 1, 2015 - December 31, 2015 training year.
Employee # 5, a counselor, was hired in January of 2012. Employee record #5 contained documentation of 5 clock hours of annual training for the January 1, 2015 - December 31, 2015 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Oversight of Mazzitti & Sullivan Human Resources operations will fall under the direction of Pyramid Healthcare. Effective 9/1/16 all Mazzitti & Sullivan clinical staff will be trained on the use of myLearningPointe a web based Learning Management System (LMS). Furthermore, this LMS will track staff trainings and will alert staff and their supervisor when staff are out of compliance with training requirements. Staff identified will obtain the 25hrs by 10/1/2016. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Six employee records were reviewed on June 6, 2016. One out of the six employee records was required to contain an annual evaluation for the employee. The facility failed to document an annual evaluation in employee record #5.
Employee #5 was hired on January 23, 2012 and there was no documentation of an annual evaluation since the day of hire.
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Plan of Correction
Mazzitti & Sullivan will conduct annual performance evaluations on all staff in September 2016 and annually thereafter. This process will be conducted in unison with Pyramid Healthcare's annual performance evaluation process, and will be managed by Pyramid Healthcare's Human Resources department. |
709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
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Observations
Six personnel records were reviewed on June 6, 2016. Job descriptions were required in all six personnel records. Employee record #6 did not have documentation of the employee's job description. An interview was conducted with the facility director pertaining to the missing documentation confirmed that it was not in the personnel records.
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Plan of Correction
In September 2016 as part of the annual performance evaluation process staff will sign-off on job descriptions and annually thereafter. Ongoing oversight of Mazzitti & Sullivan Human Resources operations will fall under the direction of Pyramid Healthcare. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Ten client records were reviewed on June 8, 2016 for informed and voluntary consent to release information forms. The facility failed to document a witness signature on an informed and voluntary consent to release information form in client record # 10.
Client #10 The facility failed to document a witness signature on the informed and voluntary consent to release information form for a client's family member in client record, #10. Additionally, the facility failed to document a witness signature on the informed and voluntary consent to release information form for a client's treatment provider in client record, #10.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Mazzitti & Sullivan Clinical Director and Regional Director of OP Services will re-train all staff on the proper completion of consents. Review of consents/releases of information will also be added to the monthly chart monitoring process. This re-training will be completed during the weekly staff meetings or as part of individual supervision. Re-training will be completed by 7/29/16. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Ten client records were reviewed on June 8, 2016 for informed and voluntary consent forms. The facility failed to document if the client was offered a copy of the informed and voluntary consent forms in records, #4, 5 and 10.
The facility forms have a place where the client is to initial whether or not the client accepted a copy of the form.
Client #4 - There was no indication on the form as to whether the client accepted or refused of a copy of the consent to release, dated January 21, 2016 for the client's funding source or the form dated January 21, 2016 for the client's health care provider.
Client #5 - There was no indication on the form as to whether the client accepted or refused of a copy of the consent to release, dated January 8, 2016 for a government agency or the form dated January 8, 2016 for the client's funding source.
Client #10 - There was no indication on the form as to whether the client accepted or refused of a copy of the consent to release, dated April 5, 2016 for the client's family member or the form dated April 5, 2016 for the client's health care provider.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The Mazzitti & Sullivan Clinical Director and Regional Director of OP Services will re-train all staff on the proper completion of consents. Review of consents/releases of information will also be added to the monthly chart monitoring process. This re-training will be completed during the weekly staff meetings or as part of individual supervision. Re-training will be completed by 7/29/16. |
709.93(a) 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:
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Observations
Ten client records were reviewed on June 6, 2016. The facility failed to maintain a complete record for client's, #1, 2 and 8.
Client #1 was admitted on May 14, 2015 and discharged on March 15, 2016. The facility failed to document client #1's discharge summary as of the date of the licensing inspection.
Client #2 was admitted on September 15, 2015 and discharged on January 26, 2016. The facility failed to document client #2's record of services, discharge summary and aftercare as of the date of the licensing inspection.
Client #8 was admitted on March 3, 2016 and was still an active client. The facility failed to document client #8's comprehensive treatment plan as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Mazzitti & Sullivan Clinical Director and Regional Director of OP Services will offer a mandatory clinical documentation training for all clinical staff. During this training staff will be re-trained on the necessary clinical documentation from intake to discharge as well as chart submission requirements. All staff will be re-trained by 9/1/16. Additionally, these elements will be part of the monthly chart monitoring process. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
On June 8, 2016, five client records requiring documentation of a physician's signature on treatment and rehabilitation plans and five client records requiring documentation of a physician's signature on treatment and rehabilitation plan updates were reviewed.
A physician did not sign the preliminary treatment plan, individual treatment and rehabilitation plan and the treatment plan updates in two of five client records reviewed, specifically, client records # 1 and 10.
Client # 1 was admitted on May 14, 2015. A physician was required to sign the comprehensive treatment plan. No physician signature was documented on the comprehensive treatment plan formulated on July 20, 2015.
Client # 10 was admitted on April 5, 2016. A physician was required to sign the comprehensive treatment plan. No physician signature was documented on the comprehensive treatment plan formulated on April 5, 2016.
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Plan of Correction
Effective 7/1/2016, Mazzitti & Sullivan developed a process to ensure the Medical Director is signing off on all documents as indicated in the MA manual, this process will be monitored by the Clinical Supervisor as part of the monthly chart monitoring process. Additionally, as part of the mandatory clinical documentation training to be provided by the Clinical Director and Regional Director of Outpatient Services, all MA signature protocols will be review. |