INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 4-5, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Mazzitti and Sullivan Harrisburg 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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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
During a licensing inspection conducted on June 4-5, 2019, the facility failed to provide documentation of an overall assessment of staff training needs, plan for addressing these needs, and an annual evaluation of the overall training plan.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will develop a Staff Development Program Plan for Mazzitti and Sullivan Counseling Services to include staff training needs, a plan for addressing these needs, and an annual evaluation of the training plan. During the month of July, Clinical Supervisors will review with staff the trainings they attended for 2019 and what they would like to see for trainings in 2020. Project Director will use this information to build the Staff Development Plan for Mazzitti and Sullivan Counseling Services. Each July each Clinical Supervisor will review with staff the trainings they would like to see for the following year, and the Project Director will update the Staff Development Plan to correspond with the upcoming year.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
During a licensing inspection conducted on June 4-5, 2019, the facility failed to ensure privacy of counseling sessions not being seen outside the counseling room. A group room in the basement had windows at street level without window treatments.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A maintenance request was submitted to Pyramid Healthcare, Inc. to complete the installation of windows covering on the two windows in the group room. Clinical Supervisor will do quarterly walk throughs of the building to ensure all windows have coverings. If they are not, a maintenance request will be submitted to get it repaired |
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
During a licensing inspection conducted on June 4-5, 2019, the facility failed to provide documentation that the employee reviewed and signed the annual evaluation.
Employee # 5 was hired on November 1, 2016 and promoted to current position on November 13, 2018. An annual evaluation had been conducted, however there was no signature documenting the employee reviewed the evaluation.
Employee # 6 was hired on October 1, 2015 and promoted to current position on August 1, 2016. An annual evaluation had been conducted, however there was no signature documenting the employee reviewed the evaluation.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director will contact the Human Resources Manager two weeks prior to the semi-annual review deadline to ensure all employees have signed off on their review. If they have not, the Project Director will reach out to the Clinical Supervisors to get the unsigned reviews signed by the staff prior to the deadline. Semi-Annual reviews will be due for staff beginning in August and at the time of the review between staff and Clinical Supervisors, they will be asked to go into ADP to sign their review.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
During a licensing inspection conducted on June 4-5, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (a)(6) and 4 Pa. Code 255.5 (b) for releases of information and/or failed to document an informed and voluntary consent to release information form prior to the disclosure of information.
Client # 3 was admitted on April 19, 2019 and was still an active client at the time of the inspection. A release to an employer dated April 24, 2019 allowed the release of nature and type of program, Prognosis, and progress in treatment. Also, there was an FMLA document that had been completed by the clinician that exceeded 255.5.
Client # 7 was admitted on September 17, 2018 and discharged on September 28, 2018. A consent to release form to a lab signed and dated September 17, 2018 did not provide the information to be release or purpose.
Client # 8 was admitted on September 15, 2018 and was still an active client at the time of the inspection. A consent to release form to a lab dated September 24, 2018 did not provide a signature by the client.
Client # 12 was admitted on March 27, 2019 and was still an active client at the time of the inspection. A consent to release form dated April 2, 2019 to a treatment coordinator did not provide a signature by the client. Also, consent to release forms dated May 7, 2019 to a lab allowed for the release of the medication administration record, history, and physical. A funding source allowed for the release of psychological assessment, psychiatric evaluation, medical administration record, and history and physical.
Client # 13 was admitted on November 6, 2018 and discharged on May 16, 2019. There were documented urinalysis tests on January 16 and December 5; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client # 14 was admitted on January 30, 2019 and was discharged on February 15, 2019. there was a consent to release form signed and dated on July 24, 2018 for an insurance company, but the consent was expired and was not updated.
An incident report that was sent to the Department on March 24, 2018 provided client identifying information and also released information to a girlfriend without a consent to release form.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will review with all staff at their staff meeting that no FMLA paperwork should be completed by the sites. Any client requesting FMLA paperwork needs to be directed back to their PCP. This will be documented in the staff meeting minutes and reviewed with staff on a quarterly basis and documented in the staff meeting minutes.
We have requested a copy of the services agreement from Quest labs and our organization which will take the place of a request of information being needed.
At the staff meeting Clinical Supervisors will show staff how to delete releases of information that were incorrectly opened during the assessment process. If this is done in error during the assessment, staff will be expected to delete the incorrect release of information immediately upon realizing it is the incorrect form. This will be reviewed by Supervisors during monthly chart audits. If there are incomplete releases, the Clinical Supervisor will review this with staff during monthly supervision and review the process to delete them and document it in their individual supervision note.
Clinical Supervisors will perform random chart audits for the next 6 months to ensure that releases are being filled out correctly and that they are all present and that if any changes or additions to collaterals have been made, that the appropriate release is present. During the Clinical Supervisor signing off on the Level of Care Assessment for their staff, they will also assure that the correct releases are present and filled out appropriately for the client. If this is not being completed the Clinical Supervisor during individual supervision will review with the clinician and document it in the supervision note
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709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
During a licensing inspection conducted on June 4-5, 2019, the facility failed to provide documentation that counseling services were being provided according to the individual treatment and rehabilitation plan four of seven client records reviewed.
Client # 1 was admitted on May 8, 2019 and was still an active client at the time of the inspection. The client ' s individual treatment plan indicated group sessions five times a week and individual sessions two times a week. The chart's record of service and progress notes indicated that the client had not received five groups and two individual sessions the week of May 26-June 1, 2019.
Client # 2 was admitted on May 16, 2019 and was still an active client at the time of the inspection. The client ' s individual treatment plan indicated group sessions five times a week and individual sessions two times a week. The chart's record of service and progress notes indicated that the client had not received five groups the week of May 26-June 1 and two individual sessions the weeks of May 19-25 and May 26- June 1, 2019.
Client # 3 was admitted on April 19, 2019 and discharged on June 4, 2019. The client ' s individual treatment plan indicated Group sessions five times a week and Individual sessions two times a week. The chart's record of service and progress notes indicated that the client had not received two individual sessions the weeks of April 28-May 4, May 5-11, May 12-18, and May 26- June 1, 2019.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The PHP regulations were reviewed with the group counselor regarding two individual sessions per week are required.
The PHP counselor will add a Memo to Chart indicating any no-shows or cancellations for the week in the client's chart to show that the sessions were attempted any why they were not completed.
During monthly chart audits by Clinical Supervisors this will be monitored to ensure that this is occurring. The chart audits will be shared with staff during their individual sessions and documented in an individual supervision note.
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709.82(d) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
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Observations
During a licensing inspection conducted on June 4-5, 2019, the facility failed to provide documentation that counseling services where being provided to the client on a regular and scheduled basis to include at least two individual and two group sessions weekly.
Client # 1 was admitted on May 8, 2019 and was still an active client at the time of the inspection. The clients Counseling services are to include two individual and two group sessions weekly. The chart's record of service and progress notes indicated that the client had not received two groups and two individual sessions the week of May 26-June 1, 2019.
Client # 2 was admitted on May 16, 2019 and was still an active client at the time of the inspection. The clients Counseling services are to include two individual and two group sessions weekly. The chart's record of service and progress notes indicated that the client had not received two groups the week of May 26-June 1 and two individual sessions the weeks of May 19-25 and May 26- June 1, 2019.
Client # 3 was admitted on April 19, 2019 and discharged on June 4, 2019. The clients Counseling services are to include two individual and two group sessions weekly. The chart's record of service and progress notes indicated that the client had not received two individual sessions the weeks of April 28-May 4, May 5-11, May 12-18, and May 26- June 1, 2019.
Client # 5 was admitted on October 26, 2018 and discharged on August 24, 2018. The clients Counseling services are to include two individual and two group sessions weekly. The chart's record of service and progress notes indicated that the client had not received two individual sessions the weeks of November 4-10 and November 18-24, 2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A treatment plan training was conducted for all staff on 6/18/19. During this training a PowerPoint was reviewed with staff indicating the proper way to write a treatment plan, including determining frequency of sessions for both group and individual. This was documented in a group supervision note.
Clinical Supervisor instructed staff that if someone is a no-show or cancels for group or individual sessions that a memo to chart must be completed documenting the cancellation and any attempts made to re-engage the client in services.
Our Electronic Health Record now provides Treatment plan reports that indicate when someone has changed a level of care. Staff are to be checking their alerts daily and addressing these treatment plan needs with the client.
During monthly chart audits this will be assessed by the Clinical Supervisors to ensure that the treatment plan is adequately reflecting the level of care and that the frequency of treatment is occurring. If it is not, the Clinical Supervisor will ensure a memo to chart is in the chart outlining the reason why this has not been met. These chart reviews will be reviewed with staff during monthly individual supervision and documented in their supervision notes.
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