INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 27, 2008, 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 March 28, 2008.
|
Plan of Correction
|
709.22(b) LICENSURE Governing Body
709.22. Governing body.
(b) If a project is publicly funded, not more than one staff member of the project may sit on the governing body at a designated time.
|
Observations
Based on a review of administrative documentation, the facility failed to ensure that no more than one staff member of the project sits on the governing body. The facility had three staff members on the governing body; specifically, the project director, the facility director and the medical director.
|
Plan of Correction
The Project Director will present the following recommendation to the Mission New Board for its consideration at its May 16, 2008 meeting. The Project Director and Clinical Director will resign from the Board leaving a five-member Board. Only the Medical Director will sit on the reconstituted Board. The Project Director will also draft changes to the Mission New Life by-laws to ensure that Board Membership remains compliant with 709.22 (b) in the future and recommend necessary changes for Board consideration at its May 16, 2008 meeting. |
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:
|
Observations
Based on a review of administrative documentation and staff interview, the facility failed to present a completed annual report.
|
Plan of Correction
The Project Director will prepare an annual report and present it to the Board of Directors at its regular meeting on May 16, 2008. With the concurrence of the Board the Project Director will make the annual report available to the public through limited distribution as well as a notice of availability in the Lancaster newspapers. The Project Director will insure that Mission New Life maintains compliance by preparing and publishing future annual reports by the end of each calendar year, which is within six months of the close of its fiscal year. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
|
Observations
Based on a review of administrative documentation, the facility failed to complete a performance report summarizing the progress towards meeting goals and objectives for 2007.
|
Plan of Correction
The Project Director will prepare a performance report summarizing progress toward Year 2007 goals and objectives and present it to the Board of Directors at its meeting on May 16, 6008. The Project Director will insure that Mission New Life maintains compliance by presenting future performance reports to the Board within three months of the end of the calendar 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.
|
Observations
Based on a review of the facility's policies and procedures, the facility failed to document treatment models used by the project. The policy and procedure manual included treatment models to be utilized, but failed to include definitions of the stated treatment models.
|
Plan of Correction
The Project Director will review Mission New Life Policy and Procedures concerning 709.24 (a)(2) related to treatment models utilized by the project and propose revisions for Board consideration at its May 16, 2008 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 Policy and Procedures and propose revisions to reflect the addition or deletion of treatment models in future use by Mission New Life. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
|
Observations
Based on a review of administrative materials, the facility failed to obtain updated letters of agreement with referral sources. The letters of agreement on file expired in 2005.
|
Plan of Correction
The Project Director will obtain new letters of agreement with all major Mission New Life referral sources. To ensure compliance in the future, the Administrative Assistant will monitor expiration dates of all referral agreements and prepare updated agreements for the Project Director's signature and forwarding to the respective referral sources for signature 60 days prior to expiration. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
|
Observations
Based on a review of administrative materials, the facility failed to have a written agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage. The written agreement on file expired in 2005.
|
Plan of Correction
The Project Director will obtain a new written agreement with Lancaster General Hospital for 24-hour emergency psychiatric and medical coverage. To ensure compliance in the future, the Administrative Assistant will monitor the expiration date of future agreements for 24-hour emergency psychiatric and medical coverage and prepare an updated agreement for the Project Director's signature and forwarding to Lancaster General Hospital for signature 60 days prior to expiration. |
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.
|
Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one client records reviewed, #6.
|
Plan of Correction
The Project Director and Clinical Director have reviewed deficiencies discovered at the February 27, 2008 site visit and developed a staff training schedule, which includes training regarding notification to clients when involuntarily terminated. To ensure compliance in the future, the Administrative Assistant will monitor client charts to ensure that counselors notify clients in writing when terminated involuntarily. The Administrative Assistant will bring any deficiencies to the Clinical Director's attention. The Clinical Director will address the issue with the non-compliant clinician during regular monthly supervision meetings. |
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.
|
Observations
Based on a review of administrative materials, the facility failed to provide written procedures for the evacuation and transfer of clients and staff to a safe location in case of an emergency.
|
Plan of Correction
The Project Director will review Mission New Life Policy and Procedures concerning 705.27 (4)(i) related to the transfer of clients and staff to a safe location and propose revisions for Board consideration at its May 16, 2008 meeting. Upon Board approval, the Project Director will schedule a staff training to review emergency procedures. To ensure future compliance with 705,27 (4)(i), the Project Director will include procedures for evacuation and transfer of clients and staff to a safe location in new employee orientation information and schedule annual refresher courses for the entire staff. |
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.
|
Observations
Based on a review of administrative materials, the facility failed to provide documentation of assignments of staff during an emergency.
|
Plan of Correction
The Project Director will review Mission New Life Policy and Procedures concerning 705.27 (4)(ii) related to assignments of staff during emergencies and propose revisions for Board consideration at its May 16, 2008 meeting. Upon Board approval, the Project Director will schedule a staff training to review staff assignments during emergencies. To ensure future compliance with 705,27 (4)(i), the Project Director will include staff assignments during emergencies in new employee orientation information and schedule annual refresher courses for the entire staff. |
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.
|
Observations
Based on a review of fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills. The same exit route was used in seven of eight fire drills.
|
Plan of Correction
The Project Director and Clinical Director have reviewed deficiencies discovered at the February 27, 2008 site visit and developed a staff training schedule, which includes training regarding the use of alternate exit routes during fire drills. To ensure compliance in the future, the Administrative Assistant will monitor fire drill records and bring any deficiencies to the Clinical Director's attention. The Clinical Director will ensure the use of alternate exit routes in future drills. |
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.
|
Observations
Based on a review of client records, the facility failed to document a drug or alcohol history to include lengths and patterns of use in six of six client records reviewed, #1, 2, 3, 4, 5 and 6.
|
Plan of Correction
The Project Director and Clinical Director will review and revise the drug and alcohol history form to include lengths and patterns of use. The Project Director will incorporate the new drug and alcohol history form into the overall Client History Questionnaire and schedule a training to familiarize staff with the revised form. To ensure compliance in the future, the Administrative Assistant will monitor client charts and bring any deficiencies to the Clinical Director's attention. The Clinical Director will address the issue with the non-compliant clinician during regular monthly supervision. The Project Director and the Clinical Director will review the effectiveness of the new form and meet with staff to make adjustments necessary to facilitate efficient and effective collection of data concerning the lengths and patterns of drug and alcohol use. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on a review of client records, the facility failed to document a personal history in one of six client records reviewed, #2. The personal histories reviewed in five of five client records lacked information on legal status, employment histories and educational histories.
|
Plan of Correction
The Project Director and Clinical Director have reviewed deficiencies discovered at the February 27, 2008 site visit and developed a staff training schedule, which includes training regarding collection of client history data. To ensure compliance in the future, the Administrative Assistant will monitor client charts and bring any deficiencies to the Clinical Director's attention. The Clinical Director will address the issue with the non-compliant clinician during regular monthly supervision. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in six of six client records reviewed, #1, 2, 3, 4, 5 and 6. The psychosocial evaluations included one word answers with no further explanation or evaluative insight given on the individual. The psychosocial evaluation was missing assets/strengths in two of six client records reviewed, #2 and 6. The psychosocial evaluation was missing potential or available support systems in one of six client records reviewed, #3.
|
Plan of Correction
The Project Director and Clinical Director have reviewed deficiencies discovered at the February 27, 2008 site visit and developed a staff training schedule, which includes training regarding completion of psychosocial evaluations. To ensure compliance in the future, the Administrative Assistant will monitor client charts and bring any deficiencies to the Clinical Director's attention. The Clinical Director will address the issue with the non-compliant clinician during regular monthly supervision. |
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
Based on a review of client records, the facility failed to document treatment plan updates in two of five client records reviewed, #4 and 6. The facility failed to document an assessment of the client's progress in relationship to the stated goals of the treatment plan in two of five client records reviewed, #3 and 5. Treatment plan updates were late in two of five client records reviewed, #2 and 3.
|
Plan of Correction
The Project Director and Clinical Director have reviewed deficiencies discovered at the February 27, 2008 site visit and developed a staff training schedule, which includes training regarding timing and content of treatment plan updates. To ensure compliance in the future, the Administrative Assistant will monitor client charts and bring any deficiencies to the Clinical Director's attention. The Clinical Director will address the issue with the non-compliant clinician during regular monthly supervision. |
709.93(a)(2) 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:
(2) Medication records.
|
Observations
Based on a review of client records, the facility failed to document medication records in two of two client records reviewed, #1 and 2. It was documented that the client was prescribed medications; however, the facility failed to document the name, dosage and frequency of the medications.
|
Plan of Correction
The Project Director and Clinical Director have reviewed deficiencies discovered at the February 27, 2008 site visit and developed a staff training schedule, which includes training regarding documentation of client medications. To ensure compliance in the future, the Administrative Assistant will monitor client charts and bring any deficiencies to the Clinical Director's attention. The Clinical Director will address the issue with the non-compliant clinician during regular, monthly supervision. |
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.
|
Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of one client records reviewed, #4. The aftercare plan had one basic goal listed with no timeframe for completion.
|
Plan of Correction
The Project Director and Clinical Director have reviewed deficiencies discovered at the February 27, 2008 site visit and developed a staff training schedule, which includes training regarding implementation and documentation of aftercare planning. To ensure compliance in the future, the Administrative Assistant will monitor client charts and bring any deficiencies to the Clinical Director's attention. The Clinical Director will address the issue with the non-compliant clinician during regular monthly supervision. |
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.
|
Observations
Based on a review of client records, the facility failed to document follow-up information in two of three client records reviewed, #5 and 6. Follow-up information was missing.
|
Plan of Correction
The Project Director and Clinical Director have reviewed deficiencies discovered at the February 27, 2008 site visit and developed a staff training schedule, which includes training regarding follow-up with clients after discharge. To ensure compliance in the future, the Administrative Assistant will monitor client charts and bring any deficiencies to the Clinical Director's attention. The Clinical Director will address the issue with the non-compliant clinician during regular monthly supervision. |