INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15, 2012 to October 16, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mid-Atlantic Rehabilitation Services - A.T.P. 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(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
Based on a review of the personnel records and the facility's Staffing Requirements Facility Summary Report form, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff.
The findings include:
From October 15, 2012 to October 16, 2012, one personnel record was reviewed for HIV/AIDS training , two personnel records were reviewed for STD/TB training , and the Staffing Requirements Facility Summary Report form was reviewed to verify that employees had HIV/AIDS and STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff. The facility failed to ensure that staff persons received a minimum of 4 clock hours of STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff in one of two records reviewed, specifically, record # 1.
Employee # 1 is the project director. The facility began providing services on July 23, 2008 and employee # 1 has been employed in his position since the program began providing services. Employee # 1 would have been due to complete 4 clock hours of STD/TB training by July 23, 2010; however, personnel record # 1 only included documentation of 3.5 clock hours of STD/TB training as of October 16, 2012.
The findings were confirmed during an interview with the project director on October 16, 2012 at approximately 9:00 A.M.
This is a repeat citation. The facility was cited on October 13, 2011 for noncompliance with this standard.
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Plan of Correction
Project Director attended a DDAP approved TB/STD training of 4 hourson 10/23/12. Copy of attendance certificate is in the personell file. By 1/31/13 Project Director will audit all personell files for HIV/AIDS and TB/STD training. Any current staff who need these trainings will be identified and required to register for the above trainings at the next scheduled training within a reasonable distance. All new hires will be informed of the need for completion of TB/STD training within the first year at the time of hire. An audit of new hires personell files will be conducted at their 90 day review to identify progress in the completion of HIV/AIDS and TB/STD training. If not registered for or completed new hires will register during their 90 day review with the project director. |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on observations on October 16, 2012, the facility failed to provide a wall mirror and soap in each bathroom.
The findings include:
A physical plant inspection was conducted on October 16, 2012. It was observed during the inspection at approximately 10:50 A.M., that there was no wall mirror and soap in the unisex handicap public bathroom on the first floor.
The findings were confirmed during an interview with the project director on October 16, 2012 at approximately 10:51 A.M.
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Plan of Correction
Mirror will be installed in bathroom by 1/31/13. Project director will develop and complete weekly a monitoring log and inspect the bathroom weekly to ensure the presence of soap and the mirror in the public first floor handicapped accesible restroom. Project director will inspect weekly all bathrooms in the facility to ensure that each bathroom has a sink, wall mirror, soap, an operable soap dispenser, and either individual paper towels or a mechanical dryer. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on observations on October 16, 2012, the facility failed to ventilate bathrooms by exhaust fan or window.
The findings include:
A physical plant inspection was conducted on October 16, 2012. It was observed during the inspection at approximately 10:50 A.M., that the unisex handicap public bathroom on the first floor was not ventilated by an exhaust fan or window.
The findings were confirmed during an interview with the project director on October 16, 2012 at approximately 10:51 A.M.
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Plan of Correction
Exhaust fan in first floor public handicap accesible restroom will be requested to be repaired by 12/16/12. The project director will develop an inspection log and inspect the restroom weekly to ensure function of the ventilation fan. The project director will inspect weekly all bathrooms in the facility to ensure that each bathroom is ventilated by an exhaust fan or window. |
709.22(c)(3) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(3) Criteria for continued membership.
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Observations
Based on an interview with the facility director, the governing body failed to adopt written policies that include criteria for continued membership.
The findings include:
On October 15, 2012 and October 16, 2012, the Licensing Specialist asked to see a copy of the facility's policy for criteria for continued membership to the board of the governing body. A copy of the facility's policy for criteria for continued membership to the board of the governing body was not presented for review.
The findings were confirmed during an interview with the project director on October 16, 2012 at approximately 8:15 A.M.
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Plan of Correction
At the board meeting scheduled for 1/3/2013 board will develop and approve a policy for continued membership. Upon approval and completion this will be included with the by-laws in the facility policcy and procedure manual. Project Director and CEO will be responsible for ensuring completion of this policy and ensuring that the policy is maintained by the board. The project director will make sure that the policy remains in place at the facility. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of clients, the facility failed to notify the client in writing of a decision to involuntarily terminate the client's treatment at the project.
The findings include:
The facility's policy titled: "Notification of Termination," states:
"MARS-ATP recognizes that on occasion, circumstances may arise that could dictate a client needs to be involuntarily discharged from treatment (i.e., violations of agency rules and regulations, etc.) In such instance, it shall be the policy of MARS-ATP to inform the client of this decision in writing."
On October 16, 2012, two client records requiring documentation that the facility notified the client in writing of a decision to involuntarily terminate the client's treatment at the project. The facility did not notify the client in writing of a decision to involuntarily terminate the client's treatment at the project in two of two records reviewed, specifically, client records # 13 and 13.
Client # 13 was admitted November 19, 2011 and was involuntarily discharged April 3, 2012. The facility was required to notify client # 13 in writing of a decision to involuntarily terminate the client's treatment by April 3, 2012. However, client record # 13 did not include documentation that the facility notified the client in writing of a decision to involuntarily terminate the client's treatment.
Client # 14 was admitted June 20, 2011 and was involuntarily discharged February 10, 2012 The facility was required to notify client # 14 in writing of a decision to involuntarily terminate the client's treatment by February 10, 2012. However, client record # 14 did not include documentation that the facility notified the client in writing of a decision to involuntarily terminate the client's treatment.
The findings were confirmed during an interview with the project director on October 16, 2012 at approximately 2:30 P.M.
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Plan of Correction
Project Director will mail discharge letters to client #13 and client #14 by 12/7/12. Inservice will be held on 11/29/12 with staff to provide education on this policy and ensure that all clinicians are awar of policy. Upon discharge Project Director will audit closed records and monitor presence of discharge letters. |
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 a psychosocial evaluation in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Outpatient Activities Intake and Admission Plan," states:
"The Psychosocial evaluation will specifically address each of the following and be completed within 30 days of admission."
On October 16, 2012, eight client records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation according to their policy and procedures in two of eight records reviewed, specifically, client records # 2 and 5.
Client # 2 was admitted April 19, 2012. The psychosocial evaluation was due May 19, 2012. However, the psychosocial evaluation in client record # 2 was not documented until May 31, 2012.
Client # 5 was admitted August 14, 2012. The psychosocial evaluation was due September 13, 2012. However, the psychosocial evaluation in client record # 5 was not documented until September 20, 2012.
The findings were confirmed during an interview with the project director on October 16, 2012 at approximately 2:30 P.M.
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Plan of Correction
An inservice will be held for all clinicians on 11/29/12 to review policy and procedure on psychosocial evaluation being completed within 30 days of admission. Chart audits will be conducted by clinical supervisor and project director to ensure compliance with policy. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan.
The findings include:
On October 16, 2012, eight client records requiring documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan were reviewed. The facility did not document the type and frequency in the individual treatment and rehabilitation plan in two of eight records reviewed, specifically, client records # 3 and 7.
Client # 3 was admitted August 8, 2012. The individual treatment and rehabilitation plan was completed August 8, 2012, but it did not include documentation of the type and frequency in the individual treatment and rehabilitation plan as of October 16, 2012.
Client # 7 was admitted April 17, 2012. The individual treatment and rehabilitation plan was completed May 29, 2012, but it did not include documentation of the type and frequency in the individual treatment and rehabilitation plan as of October 16, 2012.
The findings were confirmed during an interview with the project director on October 16, 2012 at approximately 2:30 P.M.
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Plan of Correction
Inservice will be held on 11/29/12 to address the need to follow policy regarding documentation of the type and frequency of treatment. Project Director and Clinical Supervisor will conduct audits to ensure completion of type and frequency on the treatment plan. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan.
The findings include:
On October 16, 2012, eight client records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in three of eight records reviewed, specifically, client records # 1, 3, and 7.
Client # 1 was admitted May 18, 2012. The individual treatment and rehabilitation plan was completed June 22, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of October 16, 2012.
Client # 3 was admitted August 8, 2012. The individual treatment and rehabilitation plan was completed September 12, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of October 16, 2012.
Client # 7 was admitted April 17, 2012. The individual treatment and rehabilitation plan was completed May 29, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of October 16, 2012.
The findings were confirmed during an interview with the project director on October 16, 2012 at approximately 2:30 P.M.
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Plan of Correction
Inservice will be held on 11/29/12 to ensure clinicians complete the type of support services in the individual treatment plan and treatment plan reviews. Audits of charts will be conducted to ensure that this is being completed. Audits will be conducted by clinical supervisor and Project Director. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Outpatient Activities Intake and Admission Plan," states:
"When a client is not continuing formal treatment after discharge (goals completed, goals partially completed, AMA), MARS-ATP will attempt to follow-up on the ex-client's progress by contacting the ex-client by phone or by mail. This will be done with the written consent of the client and within three months from the date of the client's discharge."
On October 16, 2012, six client records requiring documentation of follow-up information
according to their policy and procedures in three of six records reviewed, specifically, client records # 9, 10, and 14.
Client # 9 was admitted January 11, 2012 and was discharged June 28, 2012. The follow-up information was due September 30, 2012. However, the follow-up information in client record # 9 was not documented until October 11, 2012.
Client # 10 was admitted December 20, 2011 and was discharged April 28, 2012. The follow-up information was due July 31, 2012. However, the follow-up information in client record # 10 was not documented until August 22, 2012.
Client # 14 was admitted June 20, 2011 and was discharged February 20, 2012. The follow-up information was due May 31, 2012. However, the follow-up information in client record # 14 was not documented until June 11, 2012.
The findings were confirmed during an interview with the project director on October 16, 2012 at approximately 2:30 P.M.
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Plan of Correction
Inservice will be conducted for all clinicians on 11/29/12 to educate on the policy of completing follow-up within three months of discharge. Project director will monitor follow-up surveys to ensure completion within the prescribed time frame. |