INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 27, 2009 licensure renewal inspection. The follow-up inspection was conducted on March 1, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 March 30, 2010.
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Plan of Correction
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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
A follow-up inspection was conducted on March 1, 2010 and the policy and procedure manual pertaining to general safety and emergency procedures was requested. The licensing specialist was informed by the Administrative Secretary that the facility is currently working on the general safety and emergency procedures and and has not yet been updated in accordance with the plan of correction.
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Plan of Correction
The Project Director is currently revising Mission New Life's policy and procedures related to the evacuation and transfer of clients and staff in case of an emergency. He is also drafting an emergency preparedness plan to complement policy and procedures related to evacuation and transfer of clients and staff in case of emergency. The Project Director in collaboration with the Facility Director at Thirty-Nine West Vine will meet with the entire staff to review the revised policy and procedures and emergency preparedness plan. This review session will serve both for training purposes as well as to gain staff feedback for fine tuning safety and emergency procedures as well as the emergency preparedness plan. Proposed revisions will be brought to the Board at its next regular meeting scheduled for May 14, 2010. Upon Board approval, the Project Director will revise Mission New Life Policy and Procedures to include the approved policy and procedures for evacuating and transferring clients and staff in case of emergency and the revised emergency preparedness plan. To ensure compliance with 705.27(4)(i) in the future, the Project Director in collaboration with the Facility Director will annually review Mission New Life's Policy and Procedures for evacuation and transfer of clients and staff as well as Mission New Life's Emergency Preparedness Plan with the entire staff to determine whether Mission New Life is in compliance and whether improvements can be made. 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
A follow-up inspection was conducted on March 1, 2010 and the policy and procedure manual in order to review the general safety and emergency procedures was requested. I was informed by the Administrative Secretary that the facility failed to complete the documentation that they identified they would complete in their plan of correction.
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Plan of Correction
The Project Director is currently revising Mission New Life's policy and procedures related to the evacuation and transfer of clients and staff in case of an emergency. The revised policy and procedures will include assignments of staff during emergencies. The Project Director in collaboration with the Facility Director at Thirty-Nine West Vine will meet with the entire staff to review revised policy and procedures. This review session will serve both for training purposes as well as to gain staff feedback for fine tuning emergency assignments. Proposed revisions will be brought to the Board at its next regular meeting scheduled for May 14, 2010. Upon Board approval, the Project Director will revise Mission New Life Policy and Procedures to include the approved policy and procedures for assigning staff during emergencies. To ensure compliance with 705.27(4)(ii) in the future, the Project Director in collaboration with the Facility Director will annually review Mission New Life's Policy and Procedures for assigning staff during emergencies with the entire staff to determine whether Mission New Life is in compliance and whether improvements can be made. 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. |
709.24(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
A follow-up inspection was conducted on March 1, 2010. The licensing specialist requested the facility's policy and procedure manual to verify that the changes regarding treatment models as identified in the plan of correction had been completed. The facility's Administrative Secretary reported that the plans of corrections had not been completed from the last inspection.
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Plan of Correction
The Project Director has drafted a revised statement regarding treatment models utilized by the project. The draft statement was reviewed with the clinical staff on March 25, 2010 and subsequently revised again. Proposed revisions will be brought to the Board at its next regular meeting scheduled for May 14, 2010. Upon Board approval, the Project Director will revise Mission New Life Policy and Procedures to include revised definitions of treatment models utilized. 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
A follow-up inspection was conducted on March 1, 2010 and the fiscal audit was requested by the licensing specialist. An interview with the accountant identified that the facility failed to complete the audit as indicated in the plan of corrections.
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Plan of Correction
Mission New Life will maintain records and accounts of all revenues and expenditures. Within three months after the end of a fiscal year, Mission New Life will "close the books" on the fiscal year just completed and prepare a balance sheet and an income and expense statement for the fiscal year. Mission New Life will hire an independent public accountant to audit all financial activities associated with the project's drug/alcohol abuse services and provide an opinion within six months of the end of the fiscal year. Mission New Life will use QuickBooks Online to record income and expenditures as well as prepare balance sheets and income and expense statements. The Project Director will be responsible for achieving compliance. He will work with Mission New Life's independent public accountant and Mission New Life's billing agent to maintain compliance. |
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 psychosocial evaluations for eight of eight records reviewed.
The findings include:
Eight client records were reviewed on March 1, 2010. Psychosocial evaluations were required in eight client records. In accordance with the facility's policy and procedure, psychosocial evaluations are completed within 30 days after the patient's admit date.
Client record #1 failed to evaluate the client ' s assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record #2 was admitted on 12/1/09 and as of the date of inspection the patient record contained no documentation of a psychosocial evaluation.
Client record #3 was admitted on 11/16/09 and as of the date of inspection the patient record contained no documentation of a psychosocial evaluation.
Client record #4 failed to document an evaluation of the client's composite picture, problems/needs, assets and strengths, support systems, coping mechanisms, factors that might inhibit treatment, attitude toward treatment and the counselor's conclusion and impressions regarding the patient.
Client record # 5 failed to document an evaluation of the client's composite picture, problems/needs, assets and strengths, support systems, coping mechanisms, factors that might inhibit treatment, attitude toward treatment and the counselor's conclusion and impressions regarding the patient. The documentation was also eligible.
Client record #6 failed to evaluate the client's client's problems/needs, assets and strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record # 7 failed to document an evaluation of the client's composite picture, problems/needs, assets and strengths, support systems, coping mechanisms, factors that might inhibit treatment, attitude toward treatment and the counselor's conclusion and impressions regarding the patient.
Client record # 8 failed to evaluate the client's composite picture, client's problems/needs, assets and strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor's conclusion/impressions.
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Plan of Correction
The Project Director will review and, if necessary, revise the form that Mission New Life currently uses to evaluate a client's psychosocial status. The Project Director in collaboration with the Facility Director will train clinical staff on the use of the revised psychosocial form. Once a month, the Project Director will randomly pull a new client's chart from each clinician's active client list to determine whether the client's psychosocial evaluation is in compliance with Department Standards. When the Project Director finds a psychosocial evaluation not in compliance, he and the Facility Director will meet with the evaluating clinician to review particular deficiencies. The clinician will be responsible for taking corrective action. The Project Director will be responsible for achieving compliance. Once compliance is achieved, the Facility Director will be responsible for maintaining compliance. |
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 the facility failed to document short term goals with action steps in eight of eight client records reviewed.
Findings:
Eight client records were reviewed on March 1, 2010. Short and long-term goals were required in eight client records. Short term goals with action steps were not documented in client records, #1, 2, 3,4, 5, 6, 7 and 8.
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Plan of Correction
The Project Director in collaboration with the Facility Director will train the clinical staff to document short and long-term treatment goals with action steps. Once a month, the Project Director will randomly pull a new client's chart from each clinician's active client list to determine whether the client's treatment plan includes short and long-term treatment goals with action steps. When the Project Director finds a treatment plan not in compliance, he and the Facility Director will meet with the client's counselor to review particular deficiencies. The clinician will be responsible for taking corrective action. The Project Director will be responsible for achieving compliance. Once compliance is achieved, the Facility Director will be responsible for maintaining compliance. |
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 client records, the facility failed to document a treatment plan update in five of five client records.
Findings:
Eight client records were reviewed on March 1, 2010. Treatment plans updates were required in five client records. In client records #1, 2, 5 & 6 treatment plan updates were not documented. In accordance with the facility's policy and procedure treatment, plans are updated every 60 days from the date of the last treatment plan.
Client record #1 treatment plan was completed on 12/10/09 and as of the date of inspection there was no treatment plan update documented in record # 1.
Client record #2 treatment plan was completed on 12/10/09 and as of the date of inspection there was no treatment plan update documented in record # 2.
Client record #5 treatment plan was completed on 12/2/09 and as of the date of inspection there was no treatment plan update documented in record #5.
Client record #6 treatment plan was completed on 11/6/09 and as of the date of inspection there was no treatment plan update documented in record # 6.
Also, in client record #4, the documentation of the client's progress with the treatment plan goals did not include specific information in relationship to the stated goals of the treatment plan, but stated comments that were not specific to the client's progress in treatment.
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Plan of Correction
The Project Director in collaboration with the Facility Director will review with the clinical staff, agency policy regarding 60-day reviews of client treatment plans and associated procedures. If necessary, the Project Director in collaboration with the Facility Director will revise procedures for conducting sixty-day reviews and updates. The Project Director in collaboration with the Facility Director will then train the clinical staff in the implementation of revised procedures. The Office Manager will develop a system to monitor client progress and advise clinicians regarding deadlines for reviewing and updating individual treatment plans. Once a month, the Project Director will randomly pull a new client's chart from each clinician's active client list to determine whether the clinician is in compliance with Mission New Life's policy for reviewing and updating individual treatment plans every sixty days. When the Project Director finds a client chart not in compliance, he and the Facility Director will meet with the client's counselor to determine circumstances that prevented a timely review and update of the client's treatment plan. The clinician will be responsible for taking corrective action. The Project Director will be responsible for achieving compliance. Once compliance is achieved, the Facility Director will be responsible for maintaining compliance. The Facility Director will be responsible for working with the Office Manager to develop a monitoring system. Once developed, the Office Manager will be responsible for maintaining the system and monitoring sixty-day reviews. |
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 four of eight client records reviewed.
The findings include:
Eight client records were reviewed on March 1, 2010. Progress notes were required in eight records. In records #3, 4, 5 and 7 progress notes for individual sessions were illegible, pre-written, and included photocopied therapist signatures.
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Plan of Correction
Clinical staff has been informed that the use of photocopied progress notes for individual sessions is not allowed. To resolve "illegibility" concerns the Facility Director will train and encourage clinical staff to use their computers for writing progress notes. Once a month, the Project Director will randomly pull a new client's chart from each clinician's active client list to determine whether progress notes are legible, original, and signed by the clinician. When the Project Director finds a client chart not in compliance, he and the Facility Director will meet with the client's counselor to determine why progress notes are not in compliance. The clinician will be responsible for taking corrective action. The Project Director will be responsible for achieving compliance. Once compliance is achieved, the Facility Director will be responsible for maintaining compliance. |
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 documented aftercare plans in one of one discharge records reviewed.
The findings include:
Eight client records were reviewed on March 1, 2010. Aftercare plans were required in one discharge record. In accordance with the facility's policy and procedure, aftercare plans are only completed when the client successfully completed treatment. Client # 6 was admitted on November 5, 2009 and discharged on January 29, 2010; as of the date of inspection there was no aftercare plan documented in record #6.
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Plan of Correction
The Project Director in collaboration with the Facility Director at Thirty-Nine West Vine will review with the clinical staff, agency policy regarding aftercare plans and associated procedures. If necessary, the Project Director in collaboration with the Facility Director will revise procedures for developing aftercare plans. The Project Director in collaboration with the Facility Director will train the clinical staff in the implementation of revised procedures. Once a month, the Project Director will randomly pull a new client's chart from each clinician's active client list to determine whether the clinician is in compliance with Mission New Life's policy regarding aftercare plans. When the Project Director finds a client chart not in compliance, he and the Facility Director will meet with the client's counselor to determine circumstances that prevented development of an aftercare plan. The clinician will be responsible for taking corrective action. The Project Director will be responsible for achieving compliance. Once compliance is achieved, the Facility Director will be responsible for maintaining compliance. |
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 the review of client records, the facility failed to document follow-up information in two of two discharge records reviewed.
The findings include:
Eight client records were reviewed on March 1, 2010. Follow-ups were required in two discharge records. In accordance with the facility's policy and procedure, follow-ups will be conducted at 30 days, 90 days and 180 days after discharge. Client record #7 was discharged on 1/22/10 and as of the date of inspection there was no documentation of follow-up in the record. Client record #8 was discharged on 1/08/10 and as of the date of inspection there was no documentation of follow-up in the record.
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Plan of Correction
The Project Director will review and revise Mission New Life's policy related to client follow-up. The Facility Director in collaboration with the Office Manager will develop a system for monitoring due dates for follow-up contacts. At the beginning of each week, the Office Manager will identify all clients requiring follow-up contacts for that week. The Administrative Assistant under the direction of the Office Manager will attempt follow-up contacts for each client on the Office Manager's list. Initial contact attempts will be by phone if the client's number is known. If phone contact is not made, a letter will be mailed to the client's last known address inviting the client to call Mission New Life. If contact is made, the results of the contact will be noted in the client's chart. If contact is not made, the attempts to contact will be noted with reasons why contact was not made. The Project Director in collaboration with the Facility Director will then train the administrative staff in the implementation of revised policy and procedures. Once a month, the Project Director will randomly pull five charts of discharged clients to determine whether the charts are in compliance with Mission New Life's policy for contacting discharged clients. When the Project Director finds a client chart not in compliance, he and the Facility Director will meet with the Office Manager and the Administrative Assistant to determine circumstances that prevented a timely follow-up contact. The Office Manager will be responsible for taking corrective action. The Project Director will be responsible for achieving compliance. Once compliance is achieved, the Facility Director will be responsible for maintaining compliance. The Facility Director will be responsible for working with the Office Manager to develop a monitoring system. Once developed, the Office Manager will be responsible for maintaining the system and monitoring follow-up contacts. |