INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mission New Life 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 September 22, 2009.
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Plan of Correction
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records and conversation with the Facility Director/Clinical Supervisor it was confirmed that the facility failed to demonstrate that performance evaluations were conducted semi-annually for counselor assistant.
The findings were:
Four personnel records were reviewed on August 27, 2009. Supervision of Counselor Assistant was required in one personnel record. Employee #4 started on 7/5/2007 and as of this date only one performance evaluation was documented.
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Plan of Correction
The Clinical Supervisor will meet with the Counselor Assistant to identify measurable performance standards related to the Counselor Assistant's counseling. These will serve as measures of performance for semiannual performance reviews by the Clinical Supervisor. Results of semiannual performance reviews will determine the Counselor Assistant's status. The Project Director will hold the Clinical Supervisor accountable for developing measurable performance standards with the Counselor Assistant, for performing semiannual reviews, and for documenting these reviews in the Counselor Assistant's personnel records. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of the personnel records, the facility failed to ensure that the counselor assistant documented to the facility director that he is working toward counselor status.
The findings include:
Four personnel records were reviewed on August 27, 2009. Counselor Assistant documentation of working toward counselor status was required in one personnel record. The counselor assistant did not document to the facility director that he is working toward counselor status in personnel record # 4.
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Plan of Correction
The Counselor Assistant, certified as an Associate Addiction Counselor II, was hired on June 7, 2007. He is currently enrolled in Lincoln University's Master of Human Services Program (MHS). The MHS Program takes two years (four 15-week semesters and a mandatory 8-week summer semester) to complete, and leads to a Master of Human Services degree. The Clinical Supervisor will meet with the Counselor Assistant to lay out a semester-by-semester schedule of required courses. The Counselor Assistant will use this schedule as well as reports of academic performance to prepare written documentation at the end of each calendar year (beginning with 2009) of progress toward his Master of Human Services degree. The Clinical Supervisor will file this documentation in the Counselor Assistant's personnel records. The Project Director will hold the Clinical Supervisor accountable for obtaining annual reports from the Counselor Assistant and for filing documentation in the Counselor Assistant's personnel records. |
705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
Based on review of the facility's policy and procedure manual, the facility failed to provide a written procedure for staff and clients to follow in case of an emergency.
The findings include:
The policy and procedure manual was reviewed on August 27, 2009; the facility policy and procedure manual did not include a written procedure for evacuation and transfer of staff and clients to follow in the event of an internal and external emergency.
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Plan of Correction
The Mission New Life Project Director will review and update Mission New Life's policy and procedure regarding the evacuation and transfer of clients and staff in case of emergency. The Project Director will submit the updated policy and procedure to the Mission New Life Board for its review and approval and then instruct and train the Mission New Life staff on the execution of procedures in the case of an actual emergency. The Board will hold the Project Director accountable for reviewing all Mission New Life policy and procedures at least annually and updating them as necessary and appropriate. |
705.27 (4) (ii) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(ii) Assignments of staff during emergencies.
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Observations
Based on review of the facility's policy and procedure manual, the facility failed to provide written procedures for staff and clients to follow in case of an emergency.
The findings include:
The policy and procedure manual was reviewed on August 27, 2009. The facility policy and procedure manual did not include a written procedure for staff and clients to follow in case of an emergency which shall include provisions for assignments of staff during emergencies.
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Plan of Correction
The Mission New Life Project Director will review and update Mission New Life's policy and procedure regarding assignments of staff during emergencies. The Project Director will submit the updated policy and procedure to the Mission New Life Board for its review and approval and then instruct and train the Mission New Life staff on the execution of the updated policy and procedures in the case of an actual emergency. The Board will hold the Project Director accountable for reviewing all Mission New Life policy and procedures at least annually and updating them as necessary and appropriate. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative documentation on August 27, 2009 it was determined that the project failed to make the annual report available to the public.
The findings were:
During the review of the project's policy manual the project did not make the annual report available to the public within six months from the end of the project's fiscal year for 2008. The facility fiscal year runs from January to December of each year.
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Plan of Correction
The Project Director presented an Annual Report for Year 2008 to the Board on September 18, 2009. The Board approved the Year 2008 Annual Report and authorized its publication. The Project Director will advertise the availability of the Year 2008 Annual Report in the Lancaster Newspapers, the Lancaster Law Review, the Patriot News, and the Dauphin County Reporter. The Board will hold the Project Director accountable for publishing future Annual Reports within six months of the end of each fiscal year. |
709.24(a)(2) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Treatment models utilized by the project.
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Observations
Based on the review of the administrative manuals, the facility failed to document treatment model definitions in the agency manual.
The findings included :
The agency manuals were reviewed on August 27, 2009. It was noted during the inspection that the treatment models utilized were named; however, the facility failed to define the treatment models in the agency manual.
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Plan of Correction
The Project Director will review Mission New Life's Policy and Procedures concerning 709.24 (a)(2) related to treatment models utilized by the project and propose revisions for Board consideration at its next regular meeting. Upon Board approval, the Project Director will revise Mission New Life Policy and Procedures to include definitions of the stated treatment models. To ensure compliance with 709.24(a)(2) in the future, the Project Director will annually review Mission New Life's Policy and Procedures and propose revisions to reflect the addition or deletion of treatment models in use by Mission New Life counselors. The Board will hold the Project Director accountable for reviewing all Mission New Life policy and procedures at least annually and updating them as necessary and appropriate. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of the policy and procedure manuals the project failed to provide a completed audit by an independent public accountant for the project's fiscal year.
The findings include:
A review of the policy and procedure manual was conducted on August 27, 2009. The facility failed to provide a completed audit by the end of the 2008 fiscal year. The facility fiscal year runs from January to December each year.
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Plan of Correction
When Mission New Life incorporated as a non-profit, it changed its fiscal year from January through December to July through June. July of 2008 through June of 2009 was Mission New Life's first full fiscal year as a non-profit organization. The Project Director will procure an independent public accountant to conduct an audit of Mission New Life's financial activities during Fiscal Year 2008-2009. This will be done within six months of the end of the fiscal year as required in section 709.25(a) of the Department Regulations. The Board will hold the Project Director accountable for procuring an annual audit of financial activities associated with the project's drug and alcohol abuse services. |
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 the review of client records on August 27, 2009 the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in four of eight client records.
Findings:
Eight client records were reviewed on August 27, 2009. Consent to release information forms were required in eight client records. Client record #1 and record #4 had a consent to release information to Lancaster County Drug and Alcohol Commission. This consent exceeded the information that is allowed to be released. The form allowed for the release of consent forms, record of services and monitoring of the client's treatment plan. Additionally, record #4 had a consent signed by the client that did not state who would receive the information; however, the reason was indicated as "other Health Insurance." Additionally, the witness did not sign and date this consent. Record #7 had a consent to release signed on 2/9/2009 for the Office of Medical Assistance; this form did not have a reason or purpose for the consent marked. In record # 8 there was documentation of a letter that notified an individual that the client was admitted to the program. There was no consent to release information documented for this individual in this client record.
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Plan of Correction
To bring the West Vine Street Clinic into compliance with section 709.28(c) of the Department Regulations, The Facility Director plans a three-pronged approach. First, the Project Director together with the Facility Director will review Mission New Life's policy and procedures regarding confidentiality of client information with all counselors in a weekly staff meeting. Mission New Life counselors will be instructed to comply with Chapter 255.5, State Plan for the Prevention, Treatment and Control of Drug and Alcohol Abuse, which states in part, "Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, . . . shall be restricted to the following: (1) whether the client is or is not in treatment; (2) client's prognosis; (3) the nature of the project; (4) a brief description of the client's progress; and (5) a short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse." Second, the Clinical Supervisor will review in individual supervisory sessions with the counselors responsible for the charts in non-compliance, the deficiencies found by the site inspectors. Thirdly, an outside expert, one of the Program Directors at the Philhaven Behavioral Healthcare Organization, will provide monthly training sessions until random checks of client charts indicate that all counselors are in compliance with section 709.28(c) regarding the disclosure of client information. The Project Director will hold the Facility Director accountable for carrying out this plan and bringing the Vine Street Clinic into compliance with section 709.28(c). |
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 eight records reviewed.
The findings included:
Eight clients records were reviewed on August 27, 2009. Drug histories were required in eight client records. Six out of eight records failed to detail the lengths and patterns of the individual's drug and/or alcohol history, specifically in records #1, 2, 3, 4, 7 and 8.
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Plan of Correction
The Project Director in conjunction with the Facility Director at the West Vine Street Clinic will review Mission New Life's policy and procedures related to documentation of client use and abuse of drug and alcohol with the objective of identifying a more effective instrument. The new instrument will be incorporated into procedures for collecting client histories. The Project Director together with the Facility Director will review the new instrument with the counseling staff in a weekly staff meeting. In addition, the Clinical Supervisor will review in individual supervisory sessions with the counselor responsible, the deficiencies found by the site inspectors. And finally, an outside expert, one of the Program Directors at the Philhaven Behavioral Healthcare, will provide monthly training sessions on collecting and documenting client history data until random checks of client charts indicate that all counselors are in compliance with section 709.91(b)(3)(ii) regarding drug and alcohol histories. The Project Director will hold the Facility Director accountable for carrying out this plan and bringing the Vine Street Clinic into compliance with section 709.91(b)(3)(ii). |
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 the review of client records the facility failed to document complete psychosocial evaluations for six out of eight records reviewed.
The findings included:
Eight client records were reviewed on August 27, 2009. Psychosocial evaluations were required in eight client records. The facility failed to document an assessment of the client's needs and problems, assets and strengths, support systems, coping mechanisms and negative factors that could effect treatment. The counselor's conclusions and impressions were not documented in 6 of 8 records reviewed, client records # 1, 2, 3, 4, 7 and 8.
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Plan of Correction
To bring the West Vine Street Clinic into compliance with section 709.91(b)(6) of the Department Regulations, the Facility Director plans a three-pronged approach. First, the Project Director together with the Facility Director will review Mission New Life policy and procedures regarding documentation of psychosocial evaluations in a weekly staff meeting. Second, the Clinical Supervisor will review in individual supervisory sessions, the deficiencies found by the site inspectors. Thirdly, an outside expert, one of the Program Directors at the Philhaven Behavioral Healthcare, will provide monthly training sessions until random checks of client charts indicate that all counselors are in compliance with section 709.91(b)(6) regarding documentation of psychosocial evaluations. The Project Director will hold the Facility Director accountable for carrying out this plan and bringing the Vine Street Clinic into compliance with section 709.93(a)(11). Finally, the Project Director will review Mission New Life Policy and Procedures regarding documentation of psychosocial evaluations to determine whether a more effective form can be developed to capture required information. The Project Director will make necessary policy and procedural adjustments to accomplish these changes. The Board will hold the Project Director accountable for making necessary policy and procedures changes. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records it was determined that the facility failed to ensure that the short-term and long-term goals in the individual treatment plan were formulated by both the staff and the client in six of eight client records.
The findings were:
Eight client records were reviewed on August 27, 2009 for treatment plan content. specifically #1,2,3,4,5 and 8 on August 27, 2009 indicated the individual treatment and rehabilitation plan documented in records #1 failed to include action steps on the master treatment plan. Additionally, the target date was the same date that the treatment plan was developed. Record #2 the treatment plan was due on 6/30/2009. The plan was not completed until 7/7/2009. Documentation in client record #3 failed to include action steps on the master treatment plan. Additionally, the target date was the same date that the treatment plan was developed. The client also did not sign this treatment plan. Record #4 had a treatment plan completed on 8/12/2009; however, the client failed to sign the treatment plan. Record # 5 failed to include long and short term goals in the Master Treatment Plan completed on 4/20/2009. Record #8 failed to include action steps on the master treatment plan. Additionally, the target date was the same date that the treatment plan was developed .
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Plan of Correction
To bring the West Vine Street Clinic into compliance with section 709.92(a)(1) of the Department Regulations, the Facility Director plans a three-pronged approach. First, the Project Director together with the Facility Director will review Mission New Life policy and procedures regarding the development of short and long-term treatment goals in a weekly staff meeting. Second, the Clinical Supervisor will review in individual supervisory sessions with the counselor responsible, the deficiencies found by the site inspectors. Thirdly, an outside expert, one of the Program Directors at the Philhaven Behavioral Healthcare, will provide monthly training sessions until random checks of client charts indicate that all counselors are in compliance with section 709.92(a)(1) regarding short and long-term treatment goals. The Project Director will hold the Facility Director accountable for carrying out this plan and bringing the Vine Street Clinic into compliance with section 709.92(a)(1). |
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 eight client records it was determined that the facility failed to document a treatment plan update in three of four client records.
The findings were:
Eight records were reviewed on August 27, 2009. Four of eight records required treatment plan updates. Three of four records did not include a treatment plan update. The Master Treatment Plan was completed on 6/4/2009 in record # 1. Record # 1 required a treatment plan update on 8/4/2009. The facility failed to document the treatment plan update.
Record # 5 required a treatment plan update on 6/20/2009. The facility failed to document the treatment plan update. Record # 7 required a treatment plan update on 5/23/2009. The facility failed to document the treatment plan update.
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Plan of Correction
To get the West Vine Street Clinic in compliance with section 709.92(b) of the Department Regulations, the Facility Director plans a three-pronged approach. First, the Project Director together with the Facility Director will review Mission New Life policy and procedures regarding review and update of treatment plans in a weekly staff meeting. Second, the Clinical Supervisor will review, in individual supervisory sessions with the counselors responsible, the deficiencies found by the site inspectors. Thirdly, an outside expert, one of the Program Directors at Philhaven Behavioral Healthcare, will provide monthly training sessions until random checks of client charts indicate that all counselors are in compliance with section 709.92(b) regarding review and update of client treatment plans. The Project Director will hold the Facility Director accountable for carrying out this plan and bringing the Vine Street Clinic into compliance with section 709.92(b). |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to clearly document progress notes in five of eight records reviewed.
The findings includes:
Eight client records were reviewed on August 27, 2009. Progress notes were required in eight records. In records #1, 2, 3, 4 and 8 clinicians did not include their assessment or plan in group notes. Also, in records #1 and 4 the progress notes for individual sessions were illegible.
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Plan of Correction
To bring the West Vine Street Clinic into compliance with section 709.93(a)(5) of the Department Regulations, the Facility Director plans a four-pronged approach. First, the Project Director together with the Facility Director will review Mission New Life policy and procedures regarding documentation of client progress in a weekly staff meeting. Second, the Clinical Supervisor will review in individual session with the counselors responsible for the charts in non-compliance, the deficiencies found by the site inspectors. Thirdly, an outside expert, one of the Program Directors at the Philhaven Behavioral Healthcare, will provide monthly training sessions until random checks of client charts indicate that all counselors are in compliance with section 709.93(a)(5) regarding documentation of client progress. Fourth, the Facility Director in conjunction with the Project Director will procure additional computers so that progress notes can be typed rather than hand written (and thus, illegible). The Project Director will hold the Facility Director accountable for carrying out this plan and bringing the Vine Street Clinic into compliance with section 709.93(a)(5). |
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 plans in three of three records.
The findings include:
Eight client records were reviewed on August 27, 2009. Aftercare plans were required in three client records that were reviewed. The facility did not document goals with time frames in the aftercare plan in client records #5 and # 7. The facility failed to complete an after care in record # 6. In records # 5, 6, and 7 the facility failed to document a contact person as well as the re-entry process.
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Plan of Correction
To bring the West Vine Street Clinic into compliance with section 709.93(a)(9) of the Department Regulations, the Facility Director plans a three-pronged approach. First, the Project Director together with the Facility Director will review Mission New Life policy and procedures regarding aftercare planning in a weekly staff meeting. Second, the Clinical Supervisor will review in individual supervisory sessions with the counselor responsible for the charts in non-complicance, the deficiencies found by the site inspectors. Thirdly, an outside expert, one of the Program Directors at the Philhaven Behavioral Healthcare, will provide monthly training sessions until random checks of client charts indicate that all counselors are in compliance with section 709.93(a)(9) regarding aftercare planning. The Project Director will hold the Facility Director accountable for carrying out this plan and bringing the Vine Street Clinic into compliance with section 709.93(a)(9). |
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 two of two client records.
Findings:
Eight client records were reviewed on August 27, 2009. Follow-up information was required in two client records. In accordance with the facility's policy follow-ups will be done 30, 90 days and 180 days after discharged if not being referred. In the event of a transfer follow-up would be required in seven days following transfer. Follow-up information was not documented in records # 7 and 8. Client # 7 was discharged on 5/26/2009. Follow-up should have occurred on 6/26/2009. Client # 8 was discharged on 4/23/2009. Follow-up should have occurred on 4/30/2009.
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Plan of Correction
To bring the West Vine Street Clinic into compliance with section 709.93(a)(11) of the Department Regulations, the Facility Director plans a three-pronged approach. First, the Project Director together with the Facility Director will review Mission New Life policy and procedures regarding follow-ups with discharged clients in a weekly staff meeting. Second, the Clinical Supervisor will review in individual supervisory sessions with the counselors responsible for the charts in non-compliance, the deficiencies found by the site inspectors. Thirdly, an outside expert, one of the Program Directors at the Philhaven Behavioral Healthcare, will provide monthly training sessions until random checks of client charts indicate that all counselors are in compliance with section 709.93(a)(11) regarding follow-up contacts for discharged clients. The Project Director will hold the Facility Director accountable for carrying out this plan and bringing the Vine Street Clinic into compliance with section 709.93(a)(11). Finally, the Project Director will review Mission New Life Policy and Procedures regarding follow-ups to reduce the number of follow-up contacts required and make necessary policy and procedural adjustments to accomplish these changes without compromising Department regulations. The Board will hold the Project Director accountable for making necessary policy and procedures changes. |