INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21, 2009 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 February 23, 2009..
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Plan of Correction
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on the review of personnel records, the facility failed to document semiannual performance evaluations on one of four personnel records.
Findings:
Four personnel records were reviewed on January 21, 2009. Semiannual performance evaluations were required in one personnel record. The facility did not document semiannual performance evaluations in personnel record #4. Employee #4 was hired 7/5/07 and as of to date no semiannual performance evaluations have been completed.
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Plan of Correction
The Facility Director has met with Employee #4 weekly since his hire on 7/5/07 to supervise work, to evaluate performance, and to train as needed. While the Facility Director has documented these meetings in his own daily dairy, he has not documented them in Employee #4's personnel record. The Facility Director will prepare semiannual reports and file them in Employee #4's personnel record. The Facility Director will continue to meet with Employee #4 a minimum of once a month. The Facility Director will develop specific performance objectives in conjunction with the Counselor Assistant and prepare formal semiannual performance reports to be filed in employee #4's personnel record. These formal performance evaluations will be filed in employee #4 personnel record within a month of the end of each six-month period. The Project Director will hold the Facility Director accountable for executing the proposed plan of correction. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on the review of personnel records, the facility failed to show documentation that they are working toward counselor status in one of four personnel records.
Findings:
Four personnel records were reviewed on January 21, 2009. Documentation showing that they are working toward counselor status was required in one personnel record. The facility did not show documentation that the employee is working toward counselor status in personnel record #4. Employee #4 was hired 7/5/07.
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Plan of Correction
The Facility Director has been working with Employee #4 since his hire as a Counselor Assistant on 7/5/07 to establish a plan for achieving counselor status within five years. However, we have neglected to document progress in Employee #4's personnel record. Employee #4 has applied for admission to Lincoln University toward a Master of Human Services/Counseling Concentration. He plans to begin classes in September of this year and receive a Masters degree by June of 2012. In the future, Employee #4 will submit a written report to the Facility Director at the end of each calendar year documenting progress toward his Masters Degree. The Project Director will hold the Facility Director accountable for executing the proposed plan of correction. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of personnel records, the facility failed to have a sufficient number of staff person's onsite during the project's hours of operation in four of four personnel records.
Findings:
Four personnel records were reviewed on January 21, 2009. The facility did not show documentation that there was a sufficient number of staff person's onsite during the project's hours of operation who has their CPR certifications in records #1, 2, 3 and 4. All staff's CPR certifications expired 10/08.
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Plan of Correction
The entire Mission New Life staff's CPR certification is now current. Staff person #1 was recertified on February 21, 2009 as were staff persons # 3 and 4. Staff person #2 was recertified on January 31, 2009. Although, Mission New Life's Billing Agent works from her home office, she also was recertified on February 21, 2009 as was our new Secretary/Receptionist. Mission New Life's new Administrative Assistant had CPR certification prior to employment. Her certification is valid through June of 2010. To avoid lapsing coverage in the future, Mission New Life will stagger training at approximate six month intervals. Since most of the staff's first aid certification expires in October of this year, we will train half the staff in October in both CPR and first aid. We will then train the other half in June of 2010. In subsequent years we will split the staff between January and July trainings. We will select timing of individual staff training so that at least one person with current certification is always on site during normal hours of operation. |
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
Based on the review of the facilities policy and procedure manual, the facility failed to provide a written procedure for staff and clients to follow in case of an emergency.
The findings include:
The policy and procedure manual was reviewed on January 21, 2009; the facility policy and procedure manual did not include a written procedure for evacuation and transfer for staff and clients to follow in the event of an emergency.
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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 March 20, 2009 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.
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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:
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Observations
Based on a review of the facility's policy and procedure manual on January 21, 2009, the facility failed to document an annual report for the calendar year 2007.
The findings include:
The facility failed to provide documentation of their annual report during the licensing inspection on January 21, 2009.
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Plan of Correction
The Project Director has drafted an Annual Report for Mission New Life's Fiscal Year 2007-08. The Project Director plans to present the draft report for final review and approval at the Board's next regular meeting scheduled for March 20, 2009. With Board approval, the Project Director will distribute the Mission New Life Fiscal Year 2007-08 Annual Report to a limited mailing list as well as publish a notice of availability in the Lancaster Intelligencer Journal - New Era Newspaper. To prevent this deficiency in the future, the Project Director will report to the Board each quarter regarding progress toward Board approved goals and objectives, fiscal performance, client caseload, utilization, and client management. The Project Director will consolidate quarterly performance reports into an annual report including activities and accomplishments as well as financial statements for the preceding year. The Project Director will present the annual report to the Board for review and approval for publication. |
709.24(a)(3) 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:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on the review of the facilities policy and procedure manual, the facility failed to adopt a written procedure for the management of treatment/rehabilitation services for clients.
The findings include:
A review of facility policy and procedure on January 21, 2009, failed to document a written procedure to coordinate patient treatment and rehabilitation services.
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Plan of Correction
Mission New Life's procedure to coordinate patient treatment and rehabilitation services is documented in Section 709.24 of the Mission New Life Policy and Procedures Manual. However, this policy has not been reviewed since September 7, 2005. Nor has Section 709.24 of Mission New Life's Policy and Procedures Manual been presented to the Board for its review and approval. Actual progress in providing treatment and rehabilitation services is documented in each client chart using a Treatment Management Form. The Form lists documentation which must be processed at each stage of the treatment process including evaluation and assessment, the first hour of individual counseling, the first continued stay review, the second continued stay review, the discharge/referral review, the close-out session, referral, discharge, completion, case closure, and follow-up. The Project Director will review this policy and these procedures with Mission New Life's clinical and administrative staff to ensure adherence and where necessary revise to be more accurate and effective in meeting State Standards. The Project Director will present an updated Policy and Procedure to the Board for its review and approval at its regular meeting scheduled for March 20, 2009. Upon approval the Project Director will file the updated Policy and Procedure in Mission New Life's Policy and Procedures Manual. |
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.
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Observations
Based on the review of the facility's policy and procedure manual the facility failed to to provide documentation of current letters of agreement with referral sources.
The finding include:
Referral agreements were reviewed on January 21, 2009; the facility failed to provide updated letters of agreement with referral sources. The letters of agreements on file expired in 2005.
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Plan of Correction
Mission New Life has already initiated a plan for updating letters of agreement with referral sources. Mission New Life now has current Reciprocal Referral Agreements with (1) White Deer Run of Lebanon (January 25, 2009); (2) Lancaster Clinical Counseling Associates (April 15, 2008); (3) Bowling Green of Brandywine, Inc. (February 2, 2009): (4) Conewago Pottsville (February 8, 2009); Nuestra Clinica Behavioral Health Services (January 28, 2009); and (5) Valley Forge Medical Center (February 6, 2009). Mission New Life plans to update Reciprocal Referral Agreements on an ongoing basis at the rate of four per month until agreements have been executed with all primary referral sources. Mission New Life's Billing Agent will prepare draft agreements for the Project Director's signature and execution with Mission New Life's respective referral sources. |
709.91(a)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(1) Criteria for admission.
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Observations
Based on the review of the facilities policy and procedure manual, the facility failed to include a written plan that addressed client intake and admission criteria.
The findings include:
Based on the review of the facility's policy and procedure manual, the facility failed to include a written plan that documented client intake and admission criteria.
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Plan of Correction
Mission New Life's written plan providing for intake and admission, which include criteria for admission is documented in Section 709.91 of the Mission New Life Policy and Procedures Manual. However, this policy has not been reviewed since October 1, 2005. Nor has Section 709.91 of Mission New Life's Policy and Procedures Manual been presented to the Board for its review and approval. The Project Director will review Mission New Life's plan providing for intake and admission and revise as necessary. The updated policy will be presented to the Board at its next regular meeting scheduled for March 20, 2009. Upon approval the Project Director will file the updated Policy and Procedure in Mission New Life's Policy and Procedures Manual.
Completion Date: March 31, 2009
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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.
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Observations
Based on the review of client records, the facility failed to document personal histories in five of six client records.
The findings:
Six client records were reviewed on January 21, 2009. Personal histories were required in five of six client records. The facility failed to document a personal history in client records #1, 2, 3, 4 and 5. The personal histories reviewed in five client records lacked information on legal status, employment histories, family histories and educational histories.
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Plan of Correction
Mission New Life plans to monitor charts more closely to ensure that personal histories have been adequately and appropriately documented. For the next three months, the Facility Director will review client records weekly to ensure that personal histories have been adequately and appropriately documented. After the first three months, the Facility Director will continue to monitor charts randomly at least once a quarter. In cases where a minor correction is necessary, the Facility Director will ask the appropriate clinician to make the correction. Secondly, in cases where a pattern of omissions is discerned for an individual clinician, the Facility Director will incorporate necessary training into the clinician's supervisory sessions. Finally, in cases where patterns of omitted data cut across clinicians, a broader training will be incorporated into weekly staff meetings. If deficiencies persist, the Project Director will review procedures with the entire clinical staff and make whatever adjustments are necessary to meet State standards. |
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 complete psychosocial evaluations in six of six client records.
Findings:
Six client records were reviewed on January 21, 2009. Psychosocial evaluations were required in six client records. The psychosocial evaluations did not include a clinical assessment of client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, client's attitude toward treatment and the counselor's impression of the client in client records #1, 2, 3, 4, 5 and 6.
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Plan of Correction
Mission New Life plans to monitor charts more closely to ensure that psychosocial evaluations include a clinical assessment of client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors that may inhibit treatment, as well as the client's attitude toward treatment and the counselor's impression of the client. For the next three months, the Facility Director will review client records weekly to ensure that psychosocial evaluations include a clinical assessment of client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, client's attitude toward treatment and the counselor's impression of the client. After the first three months, the Facility Director will continue to monitor charts randomly at least once a quarter. In cases where a pattern of deficiencies is discerned, the Facility Director will incorporate necessary training into the clinician's supervisory sessions and into the clinician's personal development plan. If deficiencies persist after training and supervision, progressive disciplinary action will be taken. |
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 the review of client records, the facility failed to document short and long-term goals in four of six client records.
Findings:
Six client records were reviewed on January 21, 2009. Short and long-term goals were required in six client records. The facility did not document short and long-term goals with measurable action steps in client records #1, 2, 4 and 6.
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Plan of Correction
Mission New Life plans to monitor charts more closely to ensure that short and long-term goals with measurable action steps are developed and documented in client records. For the next three months, the Facility Director will review client records weekly to ensure that short and long-term goals with concrete and measurable action steps are developed and documented in client records. After the first three months, the Facility Director will continue to monitor charts randomly at least once a quarter. In cases where a pattern of deficiencies is discerned, the Facility Director will incorporate necessary training into the clinician's supervisory sessions and into the clinician's personal development plan. If deficiencies persist after training and supervision, progressive disciplinary action will be initiated |
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 complete treatment plan update in two of three client records.
Findings:
Six client records were reviewed on January 21, 2009. Treatment plans updates were required in three client records. The treatment plan updates in client records #1 and 2 did not include the client's progress in relationship to the stated goals of the treatment plan. The facility also failed to complete treatment plan updates every 60 days in client records # 1 and 2. The treatment plan update in client record #1 was completed on 12/13/08, 67 days after the completion of the treatment plan on 10/6/08. The treatment plan update in client record #2 was completed on 1/21/09, 105 days after the completion of the treatment plan on 10/6/08.
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Plan of Correction
Mission New Life plans to monitor charts more closely to ensure that treatment plan updates are completed within 60 days of admission for treatment and within every 60 days thereafter. For the next three months, the Facility Director will review client records weekly to ensure that treatment plan updates have been completed within 60 days of admission for treatment or, if applicable, within 60 days after the previous review. After the first three months, the Facility Director will continue to monitor charts randomly at least once a quarter. In cases where a pattern of deficiencies is discerned, the Facility Director will incorporate necessary training into the clinician's supervisory sessions and into the clinician's personal development plan. If deficiencies persist after training and supervision, progressive disciplinary action will be initiated. |
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.
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Observations
Based on a review of client records, the facility failed to document medication records in two of three client records.
Findings:
Six client records were reviewed on January 21, 2009. Medication records were required in three client records. The facility failed to document the dosage and frequency of use of the medications in client records #4 and 6.
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Plan of Correction
Section 709.32 of Mission New Life's Policy & Procedures Manual states that, "Mission New Life shall neither furnish any pharmaceutical services, nor administer, store, or dispense any medications." However, Section 709.93 states, "Mission New Life shall keep a complete record on each client, which shall include: . . . (2) medication records." Further, "The Primary Counselor shall be responsible for all Client Records assigned to his or her caseload." In addition, Mission New Life has developed a Medication Record Form (Form 709.93(a)(2)-A2.0) to be completed by the Client's Primary Counselor in conjunction with the Client. The form records medication prescribed for the Client, why it is prescribed, how much, how often, and who prescribed it. The form includes documentation of medication for both physical health and mental health reasons. Unfortunately, this policy is not being implemented. To avoid continued deficiency in documentation of medication, the Project Director in conjunction with the Facility Director will conduct staff training on documentation of medications. In cases where medication is reported or discovered, documentation of medication will be made an object of treatment. The Primary Counselor will complete the Medication Form in conjunction with the Client. In cases where the Client fails to provide sufficient information to complete the form, such failure will be documented in progress notes and the client confronted in a therapeutic manner. The client's response to this intervention will be reported in the counselor's progress note for the respective sessions. |
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 document progress notes in four of six client records.
Findings:
Six client records were reviewed on January 21, 2009. Individual and Group progress notes were required in five client records. The group progress notes did not have the data of the client's participation in group and the plan for the next group session in client records #1, 2, 3 and 4. Also, in client records #1, 2, 3 and 4 the individual notes were illegible.
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Plan of Correction
The Project Director and the Facility Director will review State Standards for progress notes for groups and revise its policy and procedures accordingly. The Project Director in conjunction with the Facility Director will then conduct staff training on documentation of progress notes for group sessions. We will revise our procedures to ensure that our progress notes for group sessions "includes a comment relative to each individual's response or participation in the group session" as spelled out in the Section 709.93 (5) (relating to Client Records: Progress Notes). For the next three months, the Facility Director will review client records weekly to ensure that group notes meet State standards. After the first three months, the Facility Director will continue to monitor charts randomly at least once a quarter. In cases where a pattern of deficiencies is discerned, the Facility Director will incorporate necessary training into the clinician's supervisory sessions and into the clinician's personal development plan. If deficiencies persist after training and supervision, progressive disciplinary action will be initiated. |
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 a review of client records, the facility failed to document follow-up information in three of three client records.
Findings:
Six records were reviewed on January 21, 2009. Follow-up information were required in three client records. Per the facilities policy and procedure manual reviewed on January 21, 2009 the facility has 30 days to do a follow-up once a client is discharged if not being referred.
Client record #4 was discharged on 8/28/08 and as of to date no follow-up documented. Client record #5 was discharged on 9/2/08 and as of to date no follow-up documented. Client record #6 was discharged on 7/25/08 and as of to date no follow-up documented.
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Plan of Correction
Mission New Life is assigning follow-up to our Administrative Assistant. She will set up a tracking system based on the letters of completion or letters of involuntary termination, as the case may be. The Administrative Assistant will use the date of discharge as the start date for the thirty-day follow-up window and schedule a follow-up phone call between day twenty and day thirty. Her conversation (or lack thereof, if no response) will be documented in a Contact Note and filed in the client's record. When the client does not provide us with a contact phone number, a short questionnaire with a return envelope will be mailed to his/her last known address within thirty days of completion. This action will also be documented in a Contact Note and filed in the client's record. In cases, where the client speaks only Spanish, the Administrative Assistant will delegate the follow-up phone call to our Secretary/Receptionist. The Facility Director will hold the Administrative Assistant accountable for executing this plan of correction. |