INITIAL COMMENTS
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This report is a result of an initial on-site licensure inspection conducted on Aug 17-18, 2010 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
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Plan of Correction
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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 administrative materials during the onsite inspection the facility failed to have an annual audit for the fiscal year 2008-2009 was not completed.
The findings include:
Mission New Life Policy and Procedure Manuel was reviewed on August 17, 2010 and an interview with the Facility Director and Executive Director at 10:30 AM confirmed an annual audit was not done.
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Plan of Correction
A Board approved request for an exception to the regulation requiring an annual audit of financial activities associated with Mission New Life's drug/alcohol abuse services was mailed to the Department on September 3, 2010. At its regular meeting on September 17, 2010, Mission New Life's Board unanimously ratified its approval of the request. The request is based on the financial hardship such an audit would impose on Mission New Life's $115,000 a year budget. In lieu of an annual audit, the Board respectfully requests that Mission New Life be permitted to submit copies of its internal QuickBooks financial statements and Form 990 on an annual basis. |
709.29(a) & (b) LICENSURE Retention of Client Records
709.29. Retention of client records.
(a) Client records, whether original, reproductions or microfilm, shall be kept on file for a minimum of 4 years following the discharge of a client.
(b) If the project discontinues operation, it shall make known to the Department where its records are stored.
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Observations
Based on a review of the policy and procedure manual and an interview with the Facility Director, the facility failed to have a policy in place if the project discontinues.
The findings include:
A review of the facility policy and procedure manual revealed that the facility failed to have a policy in place to make known to the Department where the client records will be stored if the facility were to close. An interview on August 17, 2010 with the Project Director confirmed that the facility failed to have a policy that addressed the storage of client records should the facility close.
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Plan of Correction
Mission New Life's Executive Director will submit for Board approval at its regular meeting on September 17, 2010, a policy regarding retention of client records for a minimum of 4 years following discharge of a client. The Executive Director will also submit to the Board, a policy regarding disposition and storage of client records as well as notification to the Department of where records would be stored should Mission New Life discontinue operations. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of service which included a chronological listing of all services provided to the client in five of five client records.
The findings include:
Five outpatient client records were reviewed on August 17, 2010. A record of service including all services provided to the client were required in five client records. The facility did not document a record of service that included all services provided in client records #1, 2, 3, 4 and 5.
Client record #1 included documentation on the service record of client contact on 7/29/2010, 7/27/ 2010, 7/13/ 2010, 6/29/2010 and 7/1/2010; the client record failed to include progress noted for the noted dates.
Client record #2 contained a progress note written but no documentation on the record of service.
Client record #3 contained progress notes for clinical contact on 6/28/10, 7/6/10, 7/7/10, 7/13/10 and 7/14/10; these dates were not documented on the record of services.
Client record #4 contained a progress note had been written on 6-8, 2010 but it was not listed on the record of service.
Client record # 5 contained no documentation of progress note written on 6/22/10, 6/29/10, and 7/1/ 2010 but was listed on the record of service.
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Plan of Correction
Mission New Life's Office Manager will review weekly all charts for clients seen during the week to ensure that all services provided during the week are listed in chronological order on the service log and that there is a progress note for each service provided. The Executive Director will review all active client charts monthly to insure that all services provided are listed in chronological order on the service log and that there is a progress note for each service provided. |
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 a review of client records, the facility failed to document progress notes in two of five client records.
The findings include:
Five client records were reviewed on August 17 through August 18, 2010. Progress notes were required in two client records. The facility did not document the clinician's assessment of each client for counseling progress notes in client records #2, and #5.
Record # 2 failed to document an assessment on a progress note on 8/3/2010.
Record #5 failed to document an assessment on a progress note on 7/20/2010.
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Plan of Correction
Mission New Life's Executive Director will review all group notes weekly to ensure that clinicians record an assessment of each individual's participation in the group. He will review monthly all progress notes for individual sessions to ensure that clinicians include an assessment of the client's current status in each progress note. |
704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
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Observations
Based of the review of the Policy Manuel the facility failed to have a written policy in place that addressed the relapse of recovering clinical personnel.
The findings include;
A review of the Policy Manuel on August 17, 2010 and an interview with the Project Director on August 18, 2010 at 1:00 PM confirmed the facility failed to document a policy for relapse of recovering clinical personnel.
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Plan of Correction
Mission New Life's Executive Director will submit for Board approval at its regular meeting on September 17, 2010, a policy addressing the relapse of recovering clinical personnel. |
704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
Based on a review of the agency policy and procedure manual, the facility failed to document a recruitment policy.
The findings include:
A review of the policy and procedure manual on August 17, 2010 and an interview on August 18, 2010 at 1:15 PM with the Project Director, confirmed the policy to address the recruitment and hiring of staff persons who are appropriate to the population to be served was not in place.
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Plan of Correction
Mission New Life's Executive Director will submit for Board approval at its regular meeting on September 17, 2010, a policy addressing the recruitment and hiring of staff persons who are appropriate to the population served by Mission New Life.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of staff individual training plans, the facility failed to document the required information for individual training plans.
The findings include:
Five staff written training plans were reviewed on August 17, 2010. Five of the staff training plans failed to have the date when the plan was developed and the signature of the employee and supervisor in place.
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Plan of Correction
As of August 15, 2010, Mission New Life's Executive Director has reviewed with each staff member their individual training plan for the Year 2010. Both the Executive Director and the staff member signed and dated their plan for the current training year. In December of this year, the Executive Director will review with each staff member their individual training plan for the Year 2011. The Executive Director and each staff member will sign and date their agreed upon individual training plan for the Year 2011. |