INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26 and July 27, 2010 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 and a plan of correction is due on August 23, 2010.
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Plan of Correction
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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 review of personnel records, the staffing requirements facility summary report, and staff interview, the facility failed to provide documentation of HIV/AIDS and TB/STD training in three of six records reviewed.
The findings include:
Eight personnel records were reviewed on July 26, 2010. Six records were required to have HIV/AIDS and TB/STD training. The facility failed to document six hours of HIV/AIDS and at least 4 hours tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum in personnel records # 4, 7, and 8.
Personnel # 4 is a counselor, hired on 5/4/2009. Counselors are required to complete the training within the first year of employment. As of the date of the inspection the facility failed to document HIV/AIDS and TB/STD training for this employee.
Personnel # 7 is an Executive Assistant, hired on 1/8/2007. This employee should have had the training within the first two years of employment. As of the date of the inspection the facility failed to document HIV/AIDS and TB/STD training for this employee.
Personnel # 8 is an Administrative Assistant, hired on 8/4/2006. This employee should have had the training within the first two years of employment. As of the date of the inspection the facility failed to document HIV/AIDS and TB/STD training for this employee.
This is a repeat citation from last year.
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Plan of Correction
The Agency Director has arranged for the Medical Director to oversee training of all staff who are required to have HIV/AIDS and TB/STD/Hep C training. Using the PA Department of Health approved outline for six hours of HIV/AIDS education and four hours of TB/STD/Hep C education will be reviewed with staff who require this training. The Agency Director is responsible to maintain staff trainings and will document in the training manual when these trainings are completed. The Agency Director will review yearly, the traning manual when staff training are completed. The Agency director will revie yearly the training needs of the staff through our annual survey and report. The agency director now knows That we can use our medical director to provide this training using the Department of Health approve outline |
709.22(e)(2) 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:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the 2009 annual report during the onsite licensing inspection of July 26, 2010 the facility failed to document a financial statement of income and expenses in the body of the annual report.
The findings include:
The annual report was reviewed during the licensing inspection on July 26, 2010. No financial statement of income and expenses was documented in this report. An interview with the project director confirmed that this was not included in the annual report.
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Plan of Correction
The Agency Director, when completing the annual report, will include a statement of income and expenses related to the clinical services provided. The Agency Director is responsible for this regulation. |
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 documents presented at the time of the inspection and an interview with the facility director, the facility failed to document an annual audit of financial activities for the year ending December 2009.
The findings included:
During the onsite licensing inspection conducted from July 26 and July 27, 2010, the fiscal documents were reviewed. The facility director was interviewed and confirmed that an annual audit was not completed for the facility.
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Plan of Correction
The Agency Director will request an exception to this regulation based upon Licensing Alert 4-97. If Mazzitti and Sullivan is not granted this exception, the Agency Director would contract for an independent audit. The agency director will direct our accouting firmto contract with an independent auditing firm on a yearly basis. At the annual owners meeting a request for an audit will be a part of the agenda. |
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 that included all required components in 6 of 6 required client records.
The finding includes:
Seven client records were reviewed on July 27, 2010. Psychosocial evaluations were required to be documented six records reviewed. The facility failed to include psychosocial evaluations that included all required components in client records # 1, 2, 3, 4, 6, and 7.
Client record # 1 failed to include an evaluation of the client's support systems and the client's attitude toward treatment.
Client record # 2 failed to include a composite picture, an evaluation of the client's problems/ needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, and attitude towards treatment and the counselor's conclusions/ impressions on the psychosocial evaluation.
Client record #3 failed to include an evaluation of the client's coping mechanisms on the psychosocial evaluation.
Client record #4 failed to include an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors on the psychosocial evaluation.
Client record # 6 failed to include an evaluation of the client's coping mechanisms.
Client record # 7 failed to include a composite picture, an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors on the psychosocial evaluation.
This is a repeat citation from last year's inspection.
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Plan of Correction
The Agency Director will conduct a training that will restructure the clinician's assessment page to include a narrative outline for therapists to follow. This narrative outline will include needs/presenting problem, strengths, risks, support systems, coping mechanisms, and conclusions. The Agency Director will review the deficiencies noted in the last licensing visit and train staff on the requirements of the new form. Chart audits will be conducted by the Quality Care Coordinator on a quarterly basis. The Agency Director is responsible for compliance of this regulation. |
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 the review of client records, the facility failed to provide documentation of a treatment plan update in one of two required records.
The findings include:
Seven client records were reviewed on July 27, 2010. Two records required treatment plan updates. The facility failed to document a treatment plan update in client record # 1. According to the facility policy and procedure manual treatment plan, updates are to be documented every sixty days. Client # 1's comprehensive treatment plan was completed on 5/12/2010. A treatment plan update was due no later than 7/12/2010. As of the date of the inspection a treatment plan update was not documented in this client record.
This is a repeat citation from last year's inspection.
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Plan of Correction
The Agency Director is responsible for this regulation. On August 27th, the Agency Director will review with the staff the areas of non-compliance in the last licensing visit. The Agency Director will direct the Quality Service Coordinator to audit charts every quarter to insure that treatment plans are updated as required. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document a case consultation in one of two required records.
The findings include:
Seven client records were reviewed on July 27, 2010. Two records required case consultations. The facility failed to document a case consolation in client record # 1. According to the facility policy and procedure manual case consultations are due quarterly. Client # 1 was admitted into treatment on 4/5/2010. A case consultation was due no later than 7/5/2010. As of the date of the inspection, a case consultation was not documented for this client record.
This is a repeat citation from last year's inspection.
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Plan of Correction
The Agency Director is responsible for this regulation. The Agency Director will review with staff that case consults are due quarterly. Quarterly chart audits will be conducted by the Quality Service Coordinator to ensure that case consults are being done quarterly. |