INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 20-21, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Mazzitti and Sullivan Counseling, Inc was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
The following deficiencies were identified during this inspection:
|
Plan of Correction
|
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.
|
Observations
The facility failed to provide documentation of required HIV/AIDS and TB/STD training for one out of eleven staff, during a personnel record review.
Staff # 12 hired as an Administrative Assistant on August 26, 2014, was due for the required HIV/AIDS and TB/STD training no later than August 26, 2016. The staff completed the TB/STD training on June 14, 2017 and the HIV/AIDS training on August 24, 2017.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As part of transition with parent company Pyramid Healthcare there have been some training processes that have not been fully understood and staff at Mazzitti and Sullivan were mistaken in believing that certain staff had previously received trainings that had not. This error caused certain staff not be receive the trainings in the required timeframe. Changes have been made and the Clinical Director now oversees and makes sure that all trainings are done and staff are updated monthly on what trainings they are missing and need to receive. |
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.
|
Observations
The facility failed to provide documentation of the required number of training hours in one out of six records, during a personnel record review.
Staff # 8 that was hired on January 23, 2012 as a contracted counselor had no training hours for the training year January 1, 2017 through December 31, 2017, as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As part of transition with parent company Pyramid Healthcare there have been some training processes that have not been fully understood and staff at Mazzitti and Sullivan were mistaken in believing that 1099 contracted employees did not need to have the required trainings. The Clinical Director now oversees the training process and ensures that everyone has monthly updates on where they stand with their training hours and ensures all the proper paperwork is in place |
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.
|
Observations
The facilty failed to ensure privacy so that counseling sessions cannot be seen outside counseling rooms. This was evidenced by a physical site inspection on June 20, 2018.
There were no window coverings in the basement group therapy room.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Leadership notified the Operations Coordinator that we need to get window coverings for the basement windows in the group room on 6/20/18. New window coverings have been ordered and will be installed upon their arrival on 8/1/18 by the Operations Coordinator. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
A review of the June 2017 through May 2018 fire drill logs was conducted during the pre-submission process.
1. The facility failed to document whether the fire alarm or smoke detector was operative during all of the fire drills.
2. Fire drill logs dated January 2018 through May 2018, the facility failed to document the time the fire drill took place, the amount of time it took for evacuation, the exit route used, and the number of persons in the facility at the time of the drill.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff will be re-trained on the appropriate completion of the fire drill logs to ensure they include the exit route, number of people, and evacuation time during the fire drills. Ongoing completion of fire drills will be monitored on a quarterly basis by the Pyramid Healthcare risk committee. |
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.
|
Observations
The facility failed to document a Release of Information form prior to disclosure in eight of nine client records reviewed on June 20 - 21, 2018.
Record #2 did not include documentation of a consent form for a family member prior to disclosure.
Record #8, 9, 10, 11, 13, 14 & 18 did not include documentation of a consent form for their funding source.
These findings were reviewed with facility staff during the licensing process.
|
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. This re-training will be completed during the weekly staff meetings or as part of individual supervision. Re-training will be completed by 7/31/18. Additionally, review of consents/releases of information will also be added to the monthly chart monitoring process conducted by the Clinical Director |
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.
|
Observations
The facility failed to provide the client individual counseling, at least twice weekly, in seven out of seven records reviewed on June 20, 2018.
Client #1 was admitted on May 23,2018 and was an active client at the time of the inspection. The treatment plan dated May 25,2018 indicated individual counseling one time weekly which does not coincide with regulatory guidelines of twice a week. There were not two individual counseling sessions for the weeks of June 3-9, 2018 and June 10-16, 2018.
Client #2 was admitted on May 23, 2018 and was an active client at the time of the inspection. There were not two individual counseling sessions for the weeks of May 27- June 2, 2018 and June 10-16, 2018.
Client #3 was admitted on May 26, 2018 and was still an active client at the time of the inspection. The treatment plan dated June 4, 2018 indicated individual counseling one time weekly which does not coincide with regulatory guidelines of twice a week. There were not two individual counseling sessions for the weeks of June 3-9, 2018 and June 10-16, 2018.
Client #4 was admitted on April 25, 2018 and was discharged on May 22, 2018. The treatment plan dated May 1, 2018 indicated individual counseling one time weekly which does not coincide with regulatory guidelines of twice a week. There were not two individual counseling sessions for the weeks of April 29-May 5, 2018, May 6-12, 2018 and May 13-19, 2018.
Client #5 was admitted on April, 18, 2018 and was discharged on May 25, 2018. The treatment plan dated April 20, 2018 indicated individual counseling sessions twice a week however there were not two individual counseling sessions for the weeks of April 22-28, 2018, April 29-May 5, 2018, May 6-12, 2018, May 13-19, 2018 and May 20-25, 2018.
Client #6 was admitted on May 23, 2018 and was discharged on June 14, 2018. The treatment plan dated May 23, 2018 indicated individual counseling one time weekly which does not coincide with regulatory guidelines of twice a week. There were not two individual counseling sessions for the weeks of May 27-June 2, 2018 and June 3-9, 2018.
Client #7 was admitted on April 17, 2018 and discharged on May 4, 2018. The treatment plan dated April 18, 2018 indicated individual counseling one time weekly which does not coincide with regulatory guidelines of twice a week. There were no individual counseling sessions documented in the clients record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Leadership at agency met during previously scheduled Operations meeting and discussed this citation specifically. Supervisors are reviewing tx plan update options to assess most flexible selections related to provision of counseling services being provided according to tx plan. Agency wide staff will be trained to make more general selection of frequency of services to allow for changes in scheduled according to IC sessions.
Staff at office have been re-trained regarding citation and reviewed the need for frequency of services to comply with individual treatment plan and the need to make appropriate changes to frequency of services based upon progress in services or increase of services. This will be reviewed with staff at the monthly extended staff meetings in July
|
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
The facility failed to document medical histories in two out of seven records. The facility also failed to document drug and alcohol histories in one out of seven records. This was during a review of client records on June 20-21, 2018.
Client #8 was admitted on January 24, 2018 and was discharged on June 12, 2018. There was no documented medical history in the client's record.
Client #14 was admitted on December 3, 2017 and was discharged on May 8, 2018. There was no documented medical or drug and alcohol history in the client's record.
This was reviewed with facility staff during the licensing process.
|
Plan of Correction
Electronic health record will retrain staff on the need to ensure that the entire level of care assessment is completed at the assessment. EMR requires signature of client for all level of care assessments to be submitted to supervisor which will assist in prompting staff to thoroughly review the document for completion and to reject those that are not complete for the clinician to then complete with the client prior to resubmitting to the supervisor for approval. |
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.
|
Observations
The facility failed to update treatment plans within 60 days in four out of seven client records, reviewed on June 20-21, 2018.
Client # 8 was admitted on January 24, 2018 and was discharged on June 12, 2018. A treatment plan was completed on February 7, 2018 and the next update was due no later than April 7, 2018; however, there was no update documented in the record at the time of the inspection.
Client # 10 was admitted on February 9, 2018 and was still active at the time of inspection. A treatment plan was completed on February 14, 2018 and the next update was due no later than April 14, 2018; however, there was no update documented in the record at the time of the inspection.
Client #11 was admitted on March 28, 2018 and was still active at the time of inspection. A treatment plan was completed on April 6, 2018 and the next update was due no later than June 6, 2018; however, there was no update documented in the record at the time of the inspection.
Client #14 was admitted on December 3, 2017 and was discharged on May 8, 2018. A treatment plan was completed on December 3, 2017 and the next update was due no later than February 3, 2018; however it was not completed until February 8, 2018.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All staff at office will be re-trained regarding need to review and update treatment plans at least every 60 days. Staff connected to clients identified in citation will also have this need incorporated individual supervision in order to ensure that clarification is completed and staff become compliant with treatment plan updates and reviewsEMR has daily report called "My Alerts" which indicates for clinical staff and supervisor needed documentation for that time period and any delinquent forms or documentation. Clinical supervision reviews MY Alerts at minimum twice weekly and all clinical staff is required to review their reports on daily basis. This process will also be re-trained and Clinical Supervisor will focus on ensuring staff are reviewing alerts on daily basis.
Following this most recent inspection, agency will be training on need to review and update treatment plans for all changes in LOC, this will address the identified issue of initial comprehensive tx plan being completed but update not occurring in timely fashion.
|
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.
|
Observations
The facility failed to document that the clients received counseling according to their treatment plans in three out of seven records reviewed on June 20-21, 2018.
Client # 8 was admitted on January 24, 2018 and was discharged on June 12, 2018. The treatment plan dated February 7, 2018, indicated group therapy twice weekly and individual counseling bi-weekly. The client did not have groups documented after May 15, 2018 and was not discharged until June 12, 2018 and individual sessions were not documented after March 14, 2018.
Client #9 was admitted on January 24, 2018 and was active at the time of inspection. The treatment plan dated January 29, 2018 indicated group therapy three times a week and individual therapy bi-weekly. The client did not have three group sessions for the weeks of:
February 18-24, 2018, February 25-March 3, 2018, March 18-24, 2018, March 25-31, 2018, April 1-7, 2018 and April 15-21, 2018. The client had no individual therapy sessions for the weeks of: February 25-March 3, 2018, March 18-24, 2018 and April 1-2018.
Client # 10 was admitted on February 9, 2018 and was still active at the time of inspection. The treatment plan dated February 14, 2018, indicated individual therapy once a week. The client had no individual therapy for the weeks of: March 18-24, 2018, April 15-21, 2018, April 22-28, 2018, April 29-May 5, 2018, May 6-12, 2018 and May 20-26, 2018. There were no documented sessions after May 30, 2018.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Leadership at agency met during previously scheduled Operations meeting and discussed this citation specifically. Supervisors are reviewing tx plan update options to assess most flexible selections related to provision of counseling services being provided according to tx plan. Agency wide staff will be trained to make more general selection of frequency of services to allow for changes in scheduled according to IC sessions.
Staff at office have been re-trained regarding citation and reviewed the need for frequency of services to comply with individual treatment plan and the need to make appropriate changes to frequency of services based upon progress in services or increase of services. The Clinical Director will ensure this is done through monthly chart audits, and monthly meetings with Clinical Supervisors
|