INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 2007 through September 19, 2007 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. The following deficiencies were identified during this inspection and a plan of correction is due on October 26, 2007.
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record, the facility failed to document alternate exit routes on the fire drill record. Alternate exit routes were not documented from December 2006 through September 2007.
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Plan of Correction
On 10/25/07 a review of Fire Drill Log was conducted by Facility Director. Although documentation was found that alternative routes were documented,all staff that coducts fire drills were instructed on the documentatiion procedures by the facility director. The office manager will be resposible for follow-up on this action plan. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of the project's policy and procedure manual and a review of client records, the facility failed to develop confidentiality procedures informing the client of their right to verbally revoke a consent to release information. The written procedures and consent forms stated that "a client may revoke a consent to release information, in writing". This was reviewed in six of six records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
As of 10/01/07, The facility director instructed admin staff to add the sentance "a client may verbally and or in writing revoke a consent to release information" to the Constent to Release Information Form. The office manager has removed and destroyed all Consent to Release Information Forms dated before 10/1/07. All new forms dated 10/1/07 have been made avaiable to each licensed site by the office manager. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a complete drug and alcohol history in six of six records reviewed, #1, 2, 3, 4, 5 and 6. Drug and alcohol histories were missing information regarding the lengths and patterns of use and the client's perception of their use.
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Plan of Correction
A training will be held on proper docuementation of drug and alcohol history in the psycho-social history by the facility director on 11/9/07/ A utilization review process will be instituted on 12/3/07 as follow up and the facility director is responsible for this procedure |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document complete psychosocial evaluations in six of six records reviewed, #1, 2, 3, 4, 5 and 6. Psychosocial evaluations were historical rather than evaluative. Support systems and negative factors that may inhibit treatment were not evaluated.
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Plan of Correction
Although the staff is highly trained in psycho-social evaluation,the detailed check list mental health assessment tool will be modified by adding comment lines for therapist to detail their observation on by 12/3/07. They will be instructed to document observations at this time. Utilization review will be conducted as a follow up to this ares. The facility director is responsible for seeing that Utilization review is completed |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records the facility failed to document aftercare plan goals with time frames in two of two records reviewed, #5 and 6.
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Plan of Correction
These aftercare plans used the term of "ongoing" for goals of mainting sobriety and attendace in 12 step meetings. It was explained to staff by the facility director on 10/12/07 that quantitative goals and objectives need to be on aftercare plan. UR will be used as follow up on this area. The facility director will be responsible to see that Utilzation is completed |