INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 11, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staff Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of twelve clock hours of annual training required for clinical supervisors in employee's #3 employee record. Employee #3 was hired as a clinical supervisor on March 28, 2018 and was still in that position at the time of the inspection. The facility's training year that was reviewed was from January 1, 2021 to December 31, 2021. Employee #3's employee record only documented 5.95 hours of annual training for the training year reviewed. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will complete trainings and will submit certificates to Executive Director by 12/1/22 to ensure trainings are completed before the end of the year. Regional Quality Manager and Executive Director reviewed training hour expectations with supervisor on 7/1/22. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staff Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of twenty- five clock hours of annual training required for counselors in employee #5's employee record. Employee #5 was hired as a counselor on March 12, 2018 and was still active in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2021 to December 31, 2021. Employee #5's employee record only documented 10.5 hours of annual training for the year reviewed. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All clinicians will submit quarterly reports on training hours to the clinical supervisors. Training hour requirements were reviewed with clinical staff on 7/1/22. |
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
Based on a review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information to the funding source in two out of the fourteen records reviewed. The facility verified that the funding sources were billed for services. Client #2 was admitted to the facility on February 9, 2022 and was still active at the time of the inspection. Client #7 was admitted to the facility on September 22, 2021 and was discharged on November 2, 2021. This is a repeat citation from June 30-July 1, 2021 licensing inspection. These finding were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor performed training on completion of releases for funding on 6/14/22 during group supervision. Updated trainings will happen monthly in staff meeting. Clinical supervisor will monitor monthly supervisions. Best effort was obtained to reach the client to notify client of confidentiality breach and create a correct release of information. HIPPA violation was reported on HIPPA violation spreadsheet. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) in one out of fourteen records reviewed. Client # 6 was admitted on September 23, 2021 and discharged on December 8, 2021. There was a consent to release information form, signed and dated on September 29, 2021 to the funding source that allowed for the release of client's history, labs, psychiatric, psychological, medical records, and physical examinations.This finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Training by clinical supervisor was completed during staff meeting on 6/14/22 regarding 4 Pa. Code 255.5 and limitations therefrom, specifically related to use of the proper form for releases when 255.5 is triggered. Updated trainings will happen monthly in staff meeting. Clinical supervisor will continue to train staff at monthly staff meetings.
Contact was attempted with this client to inform them of this brief breach of confidentiality, and the breach was filed within the internal reporting system. There was no success in reaching this client. Documentation of effort was made in the client chart.
Completion of this plan of correction occurred 06/14/2022. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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:
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Observations
Based on a review of the client records, the facility failed to develop a comprehensive treatment plan within fourteen days of admission as per the facility's policy and procedures manual in five out of seven client records reviewed. Client # 1 was admitted to the facility on January 7, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 12, 2022; however, there was no documentation that it was developed with the client. Client # 3 was admitted to the facility on January 3, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on February 2, 2022; however, there was no documentation that that it was developed with the client. Client #4 was admitted to the facility on November 11, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than November 24, 2021; however, was not developed until January 31, 2022. Client # 6 was admitted to the facility on September 23, 2021 and discharged on December 8, 2021. A comprehensive treatment plan was due no later than October 7, 2021; however, no comprehensive treatment plan was developed. Client #7 was admitted to the facility on September 22, 2021 and was discharged on November 2, 2021. A comprehensive treatment plan was due no later than October 6, 2021; however, no comprehensive treatment plan was developed. These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Training on completing treatment plans and deadlines completed on 5/31/22. Regional Quality Manager and Supervisor will continue to complete monthly chart audits to ensure compliance. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of the client records, the facility failed to document treatment plan updates within the regulatory timeframes in five out of five client records reviewed. Client #1 was admitted to the facility on January 28, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 28, 2022 and the next update was due no later than February 28, 2022; however, was not developed until April 21, 2022. Client #2 was admitted to the facility on February 9, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on February 17, 2022 and the next update was due no later than March 17, 2022; however, there was no update documented in the record at the time of the inspection. Client #3 was admitted to the facility on January 3, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on February 2, 2022 and the next treatment plan was due no later than March 2, 2022; however there was no update in the record at the time of the inspection. Client #4 was admitted to the facility on November 10, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 31, 2022 and the next update was due no later than March 1, 2022; however, there was no update documented in the record at the time of the inspection. Client #5 was admitted to the facility on October 5, 2021 and discharged on May 4, 2022. A comprehensive treatment plan was developed on October 14, 2021 and the next update was due no later than November 13, 2022; however, was not developed until December 15, 2021. The next update was due no later than January 14, 2022; however, was not developed until February 17, 2022. The next update was due no later than March 18, 2022; however, there was no update documented at the time of the inspection. These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Training on completing treatment plan updates and timelines for completing them on 5/30/22. Regional Quality Manager and Supervisor will continue to complete monthly audits to ensure compliance. |
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
Based on a review of the client records, the facility failed to ensure that the clients are receiving counseling services according to their individual comprehensive treatment plan in six out of the six client records reviewed. Client #1 was admitted to the facility on January 7, 2022 and was still active at the time of the inspection. The comprehensive treatment plan, dated January 12, 2022, indicated five group sessions per week and one individual session a week. The record of service and progress notes indicated that the client received three group sessions and no individual sessions between February 27- March 2, 2022, March 6-12, 2022 and March 13-19, 2022. Client #2 was admitted to the facility on February 9, 2022 and was still active at the time of the inspection. A comprehensive treatment plan, dated February 17, 2022, indicated five group sessions a week and one individual session a week. The record of service and progress notes indicated that the client received four group sessions between February 27- March 5, one group session and no individual sessions between March 27-April 2, and one group session and no individual sessions between April 10-16, 2022. Client #3 was admitted to the facility on January 3, 2022 and was still active at the time of the inspection. A comprehensive treatment plan, dated February 2, 2022, indicated four group sessions a week. The record of service and progress notes indicated the client received three group sessions between February 6-12, February 20-26, and two group sessions between February 27-March 5, 2022. Client #4 was admitted to the facility November 10, 2021 and still active at the time of the inspection. A comprehensive treatment plan dated, January 31, 2022 indicated four groups a week. The record of service and progress notes indicated the client received three group sessions between February 20- 26, and February 27-March 5, 2022. Client #5 was admitted to the facility on October 5, 2021 and was discharged on May 4, 2022. A comprehensive treatment plan, dated October 14, 2021 indicated five groups per week. The record of service and progress notes indicated the client received four group sessions between January 16- 22, three group sessions between January 23-29, 2022, and February 6-12, 2022. Client # 6 was admitted on September 23, 2021 and discharged on December 8, 2021. An individual treatment plan, dated September 23, 2021 indicated five groups a week and one individual session a week. The record of service and progress notes indicated the client received two group sessions between September 26-October 1, two group sessions between October 3-9, and four group sessions between October 24-30, 2021 and no individual session. This is a repeat citation from June 30, 2022-July 1, 2022 licensing inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Training on completing treatment plans with proper notation of services to be rendered was completed on 5/31/22.
Regional Quality Manager and Supervisor will continue to complete chart audits on a monthly basis to ensure compliance - both in treatment plan documentation, as well as ensuring that services are meeting what is outlined in the treatment plan.
Further, if/when a client misses a scheduled group/individual session, clinical staff were informed by the clinical supervisor during group supervision that call logs need to be made for missed appointments, and that memos need to be in the chart to document absences. This practice will be reviewed monthly during group supervision.
All treatment plans will state that group is 5X per week and individual sessions occur twice weekly, per PHP regulation. Bi-weekly supervision will take place between PHP staff and Clinical supervisor to ensure that treatment plans are completed correctly. |
709.82(d)(1) 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:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of the client records, the facility failed to ensure that the clients received individual counseling at least twice weekly in all seven client records reviewed. Client # 1 was admitted to the facility on January 7, 2022 and was still active at the time of the inspection. The record of service and progress notes indicated that the client received no individual sessions for the week of March 13, 2022. Client #2 was admitted to the facility on February 9, 2022 and was still active at the time of the inspection. The record of service and progress notes indicated that the client received no individual sessions for the week of February 27, 2022. Client #3 was admitted to the facility on January 3, 2022 and was still active at the time of the inspection. The record of service and progress notes indicated the client received no individual sessions for the week of February 6, 2022. Client #4 was admitted to the facility November 10, 2021 and still active at the time of the inspection. The record of service and progress notes indicated the client received no individual sessions for the week of February 20, 2022.Client #5 was admitted to the facility on October 5, 2021 and was discharged on May 4, 2022. The record of service and progress notes indicated the client received one individual session for the week of October 17, 2021. Client # 6 was admitted on September 23, 2021 and discharged on December 8, 2021. The record of service and progress notes indicated the client received no individual sessions for the week of October 3, 2021. Client #7 was admitted to the facility on September 22, 2021 and discharged on November 2, 2021. The record of service and progress notes indicated the client received no individual sessions for the week of October 10, 2021. These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Individual supervision occurred with all partial hospitalization staff on 5/18/22 to review the individual session requirements. Monthly chart audits will be completed by Regional Quality Manager and Supervisor to ensure ongoing compliance with this regulation. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a case consultation every ninety days as per the facility's policy and procedures manual in four out of six applicable records reviewed. Client #1 was admitted to the facility on January 7, 2022 and was still active at the time of the inspection. A case consultation was due no later than April 7, 2022; however, there was no case consultation in the record at the time of the inspection. Client #2 was admitted to the facility on February 9, 2022 and was still active at the time of the inspection. A case consultation was due no later that May 9, 2022; however, there was no case consultation in the record at the time of the inspection. Client #3 was admitted to the facility on January 3, 2022 and was still active at the time of the inspection. A case consultation was due no later than April 3, 2022; however, there was no case consultation in the record at the time of the inspection. Client #4 was admitted to the facility on November 10, 2021 and was still active at the time of the inspection. A case consultation was due no later than February 10, 2022; however, there was no case consultation in the record at the time of the inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff received training on regulations and expectations related to documenting case consults, and timelines of case consults on 5/30/2022 by Clinical Supervisor.
Clinical staff were informed of which of their active clients were missing case consultations, and were required to have their case consultations up-to-date by 06/01/2022.
Regional Quality Manager and Supervisor are responsible complete monthly chart audits to ensure compliance. |
709.83(a)(11) LICENSURE Client records
709.83. 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 provide a complete client record, which is to include follow up information within seven days of discharge per the facility's policy and procedures manual in two out of three applicable client records reviewed.Client #6 was admitted to the facility on September 23, 2021 and discharged on December 8, 2021. A follow up was due no later than December 17, 2021; however there was no follow up documented in the record at the time of the inspection. Client # 7 was admitted to the facility on September 22, 2021 and was discharged on November 2, 2021. A follow up was due no later than November 9, 2021; however, there was no follow up documented in the record at the time of the inspection. These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Training was completed on 6/7/22 with all staff regarding requirements to complete 7 day follow up calls on discharged clients by Clinical Supervisor. Regional Quality Manager and Supervisor will complete monthly chart audits to ensure compliance with this regulation. |
709.92(a) 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:
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Observations
Based on a review of the client records, the facility failed to develop a comprehensive treatment plan within fourteen days of admission as per the facility's policy and procedures manual in four out of seven records reviewed. Client #8 was admitted to the facility on December 7, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 21, 2021; however was not developed until January 4, 2022.Client #9 was admitted to the facility on January 5, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than January 19, 2022; however a comprehensive treatment plan was developed on February 16, 2022 In addition, there is no documentation that the comprehnesive treatment plan was developed with the client. Client #10 was admitted to the facility on December 2, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 16, 2021; however no comprehensive treatment plan was developed. Client #14 was admitted to the facility on November 29, 2021 and was discharged on March 31, 2022. A comprehensive treatment plan was due no later than December 14, 2021; however was not developed until March 3, 2022. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Training on completion of treatment plans and timelines for completing them occurred on 5/31/22 by Clinical Supervisor. Regional Quality Manager and Supervisor are responsible to complete monthly chart audits to ensure compliance of treatment plan completion. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of the client records, the facility failed to document treatment plan updates within the regulatory timeframes in two out of two applicable records reviewed. Client #8 was admitted to the facility on December 7, 2021 and was still active at the time of the inspection. An updated treatment plan was developed on February 22, 2022 and the next update was due no later than April 22, 2022; however the update was completed on April 28, 2022. Client #11 was admitted to the facility on October 27, 2021 and was discharged on January 25, 2022. A comprehensive treatment plan was developed on November 2, 2021 and the next update was due no later than January 2, 2022; however there was no update documented in the record at the time of the inspection. These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Training on completing treatment plan updates and timelines for the updates occurred on 5/31/22 by Clinical Supervisor. Regional Quality Manager and Supervisor are responsible to complete monthly chart audits to ensure compliance with these timelines. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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
Based on a review of the client records, the facility failed to ensure that the clients are receiving counseling services according to their individual comprehensive treatment plan in six out of seven client records reviewed. Client #8 was admitted to the facility on December 7, 2021 and was still active at the time of the inspection. The comprehensive treatment plan dated January 4, 2022, indicated four group sessions a week. The record of service and progress notes indicated that the client received three group sessions between February 27-March 5, 2022, March 13-19, 2022, and April 17-23, 2022. Client #9 was admitted to the facility on January 5, 2022 and was still active at the time of the inspection. The comprehensive treatment plan dated February 16, 2022 indicated four group sessions a week and one individual session a month. The record of service and progress notes indicated that the client received two group sessions between February 20-26, three group sessions between February 27-March 5, two group sessions between March 13-19, 2022 and no individual sessions between February 16-May 11, 2022. Client #10 was admitted to the facility on December 2, 2021 and still active at the time of the inspection. An initial treatment plan, dated December 2, 2021 indicated four group sessions a week. The record of service and progress notes indicated that the client received three group sessions between December 19-25, 2021, one group session between December 26, 2021 and January 1, 2022, and three group sessions between January 23-29, 2022. Client #11 was admitted to the facility on October 27, 2021 and was discharged on January 25, 2022. A comprehensive treatment plan, dated November 2, 2021, indicated four group sessions a week. The record of service and progress notes indicated that the client received three group sessions between November 21-27, 2022. Client#12 was admitted to the facility on July 26, 2022 and was discharged on September 15, 2021. A comprehensive treatment plan, dated August 3, 2021, indicated four group sessions a week and one individual a month. The record of service and progress notes indicated that the client received three group sessions between August 15-21, 2022, and one group session between August 22-28, 2022. In addition, there is no documentation that the client received individual sessions. Client #14 was admitted to the facility on November 29, 2021 and was discharged on March 31, 2022. An initial treatment plan, dated November 30, 2021, indicated four group sessions a week. The record of service and progress notes indicated that the client had received three group sessions between December 5-11, 2021 and three group sessions between December 26, 2021 and January 1, 2022. This is a repeat citation from June 30-July 1, 2021 licensing inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Training on completing treatment plans with the appropriate notation of services rendered occurred on 5/31/22 by Clinical Supervisor. Regional Quality Manager and Supervisor are responsible to complete monthly chart audits to ensure compliance. Clients will be statused as did not show, cancel by client, or cancel by therapist. Error will no longer be an option for therapists. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a case consultation every 90 days per the facility's policy and procedures manual in three out of five applicable client records reviewed. Client #9 was admitted on January 5, 2022 and was still active at the time of the inspection. A case consultation was due no later than April 5, 2022; however, there was no case consultation documented in the record at the time of the inspection. Client #10 was admitted to the facility on December 2, 2021 and was still active at the time of the inspection. A case consultation was due no later than March 2, 2022; however, there was no case consultation documented in the record at the time of the inspection. Client#14 was admitted to the facility on November 29, 2021 and was discharged on March 31, 2022. A case consultation was due no later than February 28, 2022; however, there was no case consultation documented in the record at the time of the inspection. These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Training occurred on 5/31/22 by Clinical Supervisor regarding how and when to document case consults and updated case consults. Regional Quality Manager and Supervisor are responsible to complete monthly chart audits to ensure compliance with this expectation. |
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 the client records, the facility failed to document a complete client record, which is to include follow up information within seven days of discharge as per the facility's policy and procedures manual in three out of four applicable records reviewed. Client #12 was admitted on July 26, 2021 and was discharged on September 15, 2021. A follow up contact was due no later than September 22, 2021; however, there is no documentation of a follow up contact in the record at the time of the inspection. Client #13 was admitted to the facility on November 10, 2021 and discharged on January 25, 2022. A follow up contact was due no later than February 1, 2022; however, there is no documentation of a follow up contact in the record at the time of the inspection. Client #14 was admitted to the facility on November 29, 2021 and discharged on March 31, 2022. A follow up contact was due no later than April 7, 2022; however, there was no documentation of a follow up contact in the record at the time of the inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Training completed with all staff on 6/7/22 by Clinical Supervisor regarding the expectation to complete 7 day follow up calls for all discharged clients. Regional Quality Manager and Supervisor are responsible to complete monthly chart audits to ensure compliance. |