INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 2011 through July 20, 2011 by staff from the Division of Drug and Alcohol 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of the agency staffing requirements facility summary report, the employee records and interviews with administrative staff, the facility failed to employ a counselor who met the requirements of having one year clinical experience.
The findings included :
Five clinical staff were reviewed on July 19, 2011. Four of these staff were designated as counselors. Employees # 6 did not have documentation of one year of clinical experience at the time of hire and therefore were not qualified to be a counselor.
An interview with the project director/ facility director confirmed this finding.
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Plan of Correction
The Agensy Director changed the job discription of Employee 6 to relflect counselor assistant status. The empolyee 6 then signed the new job description as of 7/20/11. A plan of structured supervision that had been in place is now documented and placed in the employees personnel file as of 7/22/11. The agency director has assigned the facility director at Highspire to provide supervision for employee 6 at that location which will include 1-1 supervision, chart auditing and observation. The agency director is resopnible for this area of compliance. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, and an interview with the project director/ facility director, the facility failed to ensure that staff persons and volunteers received 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.
The findings include:
The Staffing Requirements Facility Summary Report was reviewed on July 19, 2011.
The facility failed to provide documentation of the required TB/STD training for employee # 6.
Employee # 6 is was hired May 11, 2009. Employee # 6 was required to receive the required TB/STD training by May 22, 2011. The employee failed to obtain the required training as of the date of the inspection.
An interview with the project director/ facility director took place on July 19, 2011 at 11:35 a.m. and confirmed this finding.
This is a repeat citation from the July 27, 2010 and August 27, 2009 licensing inspection.
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Plan of Correction
The Agency Director has scheduled Employee 6 to be trained on TB/STD training with our Medical Director. The 4 hour training will be completed by August 31st 2011. The agency director is responsible for compliance on this regulation. The agency director will meet with Administrative staff responsibe for documenting training needs and filing training reports on a quarterly basis to insure that trainings are completed to meet reaulations. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records and an interview with the project director, the facility failed to document the completion of 12 clock hours of annual training required for project director in one of one personnel records.
The findings include:
Six personnel records were reviewed on July 19, 2011. One personnel record pertained to the project director. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the project director since February 1983. The facility training year is from January 1, 2010 through December 1, 2010. Employee # 1 had no training hours documented for the 2010 training year.
A discussion with the project director occurred on July 19, 2011 at which time it was confirmed that zero training hours were documented for the 2010 training year.
This is a repeat citation from the July 27, 2010 licensing inspection and the August 27, 2009 licensing inspection.
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Plan of Correction
The Agency Director has scheduled 12 hours of training for 2011. Training dates are 9/26/11 and 11/8/11. The agency director is responsible for compliance of this regulation. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observation it was determined that the facility failed to keep building free of hazards.
The findings include:
At 3:03 p.m. on July 20, 2011 a fire alarm pull station near the rear exit of the facility was observed to be unsecured and pulled away from the wall. The unsecured pull station presented a potential hazard. The project/facility director was interviewed and confirmed this finding.
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Plan of Correction
The Agency Director removed the fire alarm pull unit near the rear exit as of 7/21/11. All other pull units were rendered non-useable. The agency director is responsible for this area of compliance |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facility fire drill log it was determined that the facility failed to prepare alternate exit routes during fire drills.
The findings include:
The fire drill log was reviewed on July 20, 2011. Twelve months were reviewed for documentation of the use of alternate exits. The following months were reviewed: July 2010, August 2010, September 2010, October 2010, November 2010, December 2010, January 2011, February 2011, March 2011, April 2011, May 2011, June 2011, and July 2011. All twelve months had documented the same two exits being used for each fire drill (the front and back exit). The facility failed to prepare alternate exit routes for the past twelve months.
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Plan of Correction
Mazzitti and Sullivan Operation Manual has been changed 7/21/11, to reflect the use of two exits and location for staff and clients to gather during an emergency. The agency director will bring in a consultant from Kint to train staff on fire safety and fire drill management. The agency director will train staff on proper documentation of the manual and will review and sign off on the manual at eac location on a quarterly basis. August 19, 2011. t he agency director has responsiblity for this compliance area. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records and an interview with the project director/ facility director, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in two of four client records.
The findings include:
Eight client records were reviewed on July 20, 2011. Four records were required to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client records # 5 and 8.
In client record # 5, the client was admitted into treatment on March 28, 2011 and was involuntarily terminated from the project on July 12, 2011. There was no documentation of written notification to the client, at the time of the licensing inspection that the client was notified of being terminated from the program.
In client record # 8, the client was admitted into treatment on February 21, 2011 and was involuntarily terminated from the project on May 10, 2011. There was no documentation of written notification to the client, at the time of the licensing inspection that the client was notified of being terminated from the program
The project director/ facility director was interviewed on July 20, 2011 and confirmed this finding.
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Plan of Correction
The agency director has assigned a staff member to provide chart audits for each of the offices. This process will utilize Pa Dept Of health chart reveiw form as documentation that notice of termination letters are sent in the appropriate timeframe.This process has begun as of 8/5/11. Staff will be trained regarding the need to be compliant with termination of treatment notices. The agency director is responsible for this area of compliance. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records and an interview with the project director/ facility director, the facility failed to provide the client the opportunity to request reconsideration of a decision terminating treatment, in two of four client records.
The findings include:
Eight client records were reviewed on July 20, 2011. Four records were required to provide the client the opportunity to request reconsideration of a decision terminating treatment The facility failed to notify the client of the opportunity to request reconsideration of the decision to terminate treatment in client records # 5 and 8.
In client record # 5, the client was admitted into treatment on March 28, 2011 and was involuntarily terminated from the project on July 12, 2011. There was no documentation in the record that documented the client was provided an opportunity to request reconsideration of the decision to terminate treatment.
In client record # 8, the client was admitted into treatment on February 21, 2011 and was involuntarily terminated from the project on May 10, 2011. There was no documentation in the record that documented the client was provided an opportunity to request reconsideration of the decision to terminate treatment.
The project director/ facility director was interviewed on July 20, 2011 and confirmed this finding.
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Plan of Correction
The agency director has a staff member who has been designated to audit charts on a monthly basis. This staff member will review charts using Pa Dept of Health DAPL chart review forms to check that termination letters are sent in a timely fashion. Mazzitti and Sullivan Notice of termination letters do have a statement regarding the opportunity to request reconsideration of a decision terminating treatment. The agency director is responsible for compliance of this area. The chart audits have started as of 8/5/11. |
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 two of six client records.
The findings include:
Eight client records were reviewed on July 20, 2011. Six client records were required to have a treatment plan update. Per the facility policy, treatment plan updates are required to be completed within 60 days. The facility failed to document a treatment plan update in client records #3 and 8.
Record # 3 - The client was admitted on April 7, 2011. The comprehensive treatment plan was completed on April 20, 2011. The treatment plan update was due by June 20, 2011. The client was discharged on July 12, 2011. The facility failed to document a treatment plan update in this record.
Record # 8 - The client was admitted on February 21, 2011. The comprehensive treatment plan was completed on February 21, 2011. A treatment plan update was due by April 21, 2011. The client was discharged on May 10, 2011. The facility failed to document the completion of a treatment plan update in this record.
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Plan of Correction
The agency director has trained a staff member to audit charts on a monthly basis. Chart audits have begun as of 8/5/11. Therapist have been informed of this regulation not iln compliance and updated as to the timeframes for treatment plan updates as of 8/5/11. The agency director is responsible for this area of 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 policy and procedure manual, and an interview with the project/ facility director, the facility failed to document an aftercare plan in two of four client records.
The findings include:
Eight client records were reviewed on July 20, 2011. Per the facility policy, prior to discharge, an aftercare plan for each client will be formulated jointly by the client and his/her counselor and signed by each acknowledging the content of the plan at the last session. An aftercare plan was required in four client records. The facility did not document an aftercare plan in client records # 6 and 8.
In client record # 6, the client was admitted on November 22, 2010 and was discharged on March 28, 2011. There was no documentation of an aftercare plan.
In client record # 8, the client was admitted on February 21,2011 and was discharged on May 10, 2011. There was no documentation of an aftercare plan.
This was discussed and confirmed with the project/ facility director on July 20, 2011.
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Plan of Correction
The agency director changed the Operations Manual to reflect that successfully completed clients aftercare plans will be completed with the client at the time of discharge. Clients how leave treatment or transfer to other treatment systems would not require aftercare plans. The agency director has appointed a staff member to conduct chart audits monthly, that will include reviews of successfully completed clients to insure that aftercare plans are included in the charts. This process began on 8/5/11. The agency director is responsible for this area of compliance. Training staff of the above changes will take place on 8/19/11 |
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 the facility policy and procedure manual, client records, and an interview with the project/facility director, the facility failed to document follow-up in two of two required records.
The findings include:
Eight client records were reviewed on July 20, 2011. Four records were of discharged clients and two records required follow-up according to the facility policy and procedure manual. The policy and procedure manual was reviewed on July 19, 2011. The policy for follow-up client contacts stated that successfully discharged clients will be contacted by a designated staff member one month point following discharge for the purposes of follow up and told to contact the facility at any time in case of emergency. The facility failed to document follow-up in client records # 6 and 7.
Client # 6 was admitted on November 20,2 011 and was discharged on March 28, 2011. The client left against facility advice and should have been contacted by June 28, 2011. As of the date of the inspection there was no follow-up documented in the client record.
Client # 7 ws admitted January 31, 2011 and was discharged March 31,2 011. The left the facility against medical advice and should have been contacted by June 30, 2011. As of the date of the inspection there was no follow-up documented in the client record.
An interview with the project/facility director took place and confirmed these findings.
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Plan of Correction
The agency director has appoointed a staff member to conduct chart audits of all offices on a monthly basis. Training at the time of the licensing visit occurred and follow up training took place on 8/5/11. Follow up call will occur on a weekly basis when charts are audited. Therapists will be informed of the changes in follow-up calls on August 19, 2011. The agency director ils responsible for this area of complilance. |