INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 25-26, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ventilate bathrooms by an exhaust fan or window, in the second-floor lavatory. DDAP staff verified that the exhaust fan was not functioning. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A work order was placed immediately after the discovery of the inoperable exhaust fan in the 2nd floor bathroom on date of inspection, 5/26/2023. The unit required minimal repairs and has been fully operational since 5/29/2023. This issue has been resolved. Moving forward, the Executive Director will be responsible to submit a work order upon discovery of a non-working exhaust fan. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of seven applicable records reviewed.Client #4 was admitted on December 20, 2022 and was discharged January 21, 2023. The preliminary treatment plan dated December 20, 2022 and the comprehensive treatment plan dated January 11, 2023, indicated the client would attend five group treatment sessions per week. During the week of January 8-January 14, 2023 only three groups sessions were documented in the client record. Additionally, during the week of January 15-January 21, 2023 only one group session was documented in the client record. Client #5 was admitted on November 22, 2022 and was discharged December 27, 2022. The preliminary treatment plan dated November 22, 2022 and the comprehensive treatment plan dated December 6, 2022 indicated the client would attend five group treatment sessions per week. During the week of December 11-December 17, 2022 only one group session was documented in the client record. Additionally, during the week of December 18-December 24, 2022 no group sessions were documented in the client record. Client #6 was admitted on October 28, 2022 and was discharged December 13, 2022. The preliminary treatment plan dated October 28, 2022 and the comprehensive treatment plan dated November 23, 2022 indicated the client would attend five group treatment sessions per week. During the weeks of October 30-November 5, 2022 and November 6-November 12, 2022 no group sessions were documented in the client record. Client #7 was admitted on December 5, 2022 and was discharged on January 6, 2023. The preliminary treatment plan dated December 5, 2022 indicated the client would attend five group treatment sessions per week. During the weeks of December 4-10, 2022, December 11-December 17, 2022 and December 18-December 24, 2022 only three group session for each week were documented in the client record. This is a repeat citation from the July 1, 2021 and May 11, 2022 licensing inspections. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In order to abide by DDAP regulation, Clinical supervisor will work with case manager position to monitor regular attendance and accurately document instances where clients are absent from scheduled group and individual sessions with a start of August 1, 2023. In addition, clinical staff will be be re-trained in bimonthly group supervision starting August 1, 2023. Case manager will directly coordinate with clinicians on a daily basis to complete and document follow up calls for clients that have not been able to adhere to the prescribed frequency of scheduled sessions. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide individual counseling, at least twice weekly in five of seven client records. Client #3 was admitted on November 16, 2022 and was discharged on January 5, 2023. During the week of November 20-November 26, 2022 no individual sessions were documented in the client record. Additionally, during the week of December 18-December 24, 2022 only one individual sessions was documented in the client record. Client #4 was admitted on December 20, 2022 and was discharged on January 21, 2023. During the week of January 8-January 14, 2023 no individual sessions were documented in the client record. Additionally, during the week of January 15-January 21, 2023 no individual sessions were documented in the client record. Client #5 was admitted on November 22, 2022 and was discharged on December 27, 2022. During the week of December 11-December 17, 2022 no individual sessions were documented in the client record. Additionally, during the week of December 18-December 24, 2022 no individual sessions were documented in the client record. Client #6 was admitted on October 28, 2022 and was discharged on December 13, 2022. During the week of October 30-November 5, 2022 no individual sessions were documented in the client record. Additionally, During the week of November 6-November 12, 2022 no individual sessions were documented in the client record. Client #7 was admitted on December 5, 2022 and was discharged on January 6, 2023. During the week of December 4-December 10, 2022 only one individual session was documented in the client record. Additionally, during the week of December 11-December 17, 2022 only one individual session was documented in the client record. This is a repeat citation from the May 11, 2022 licensing inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor and PHP lead will work with case manager position to monitor regular attendance and accurately document instances where clients are absent from scheduled group and individual sessions. Case manager will directly coordinate with clinicians on a daily basis to complete and document follow up calls for clients that have not been able to adhere to the prescribed frequency of scheduled sessions. Staff have reviewed these standards starting in group supervision on 06/08/2023. Moving forward, this will be reviewed bimonthly in group supervision to ensure client's attendance in designated program. |
709.83(a)(11) LICENSURE Client records
709.83. 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 provide a complete client record, which is to include follow-up information within seven days of discharge, as per the facility ' s policy, in one of one applicable client record. Client #5 was admitted on November 22, 2022 and was discharged December 27, 2022. There was no documentation of a follow-up contact in the client record. This is a repeat citation from the May 11, 2022, licensing inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of August 1, 2023, completion and documentation of 7 day follow up calls will be the responsibility of our new case manager position. Clinicians will notify the case manager whenever there is any form of discharge for a client. The case manager will call and document their attempt to engage the client within the 7 day timeframe. Site coordinators will review all recent discharges with clinicians to ensure that all documentation is accurate and complete in the aftercare plan. |
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 treatment plan updates within the regulatory timeframe in two out of five applicable records reviewed.Client #12 was admitted on September 26, 2022 and was discharged o March 14, 2023. A treatment plan update was completed on September 29, 2022 and the next update was due no later than November 29, 2022; however, the next update was completed on January 12, 2023. Client #14 was admitted on December 25, 2022 and was discharged o March 8, 2023. A comprehensive treatment plan was completed on December 14, 2022 and the next update was due no later than February 14, 2023; however, the next update was completed on February 27, 2023. This was a repeat citation from the May 11, 2022 licensing inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Site coordinator and/or clinical supervisor will review caseloads during regularly scheduled individual supervision sessions to identify clients that are nearly due for review to avoid any lapses in maintaining accurate treatment plans within established timelines. In addition, treatment plan timelines will be reviewed at least monthly in group supervision. All staff will be retrained in completion of treatment plan timelines by August 1, 2023. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in five out of seven applicable records reviewed.Client #8 was admitted on April 22, 2023 and was still active at the time of the inspection. The comprehensive treatment plan dated April 24, 2023 indicated five groups per week. During the week of April 30-May 5, 2023 only three group sessions were documented in the client record. Additionally, during the week of May 14-May 20, 2023 only three group sessions were documented in the client record. Client #9 was admitted on March 28, 2023 and was still active at the time of the inspection. The comprehensive treatment plan dated April 3, 2023 indicated four groups per week. During the week of April 9- April 15, 2023 only two group sessions were documented in the client record. Additionally, during the week of April 23-29, 2023 only three group sessions were documented in the client record. Client #10 was admitted on January 25, 2023 and was still active at the time of the inspection. The comprehensive treatment plan dated February 1, 2023 indicated individual therapy twice a week. During the week of February 5-February 11, 2023 only one individual session was documented in the client record. Client #11 was admitted on November 4, 2022 and was still active at the time of the inspection. The comprehensive treatment plan dated October 27, 2022, indicated five groups weekly. During the week November 6-November 12 only four group sessions were documented in the client record. Additionally, during the week of November 20-November 26, 2022 only four groups sessions were documented in the client record. Client #14 was admitted on December 25, 2022 and discharged on March 8, 2023. The comprehensive treatment plan dated December 14, 2022 indicated five groups weekly. During the week of December 18-December 24, 2022 only two group sessions were documented in the client record. Additionally, during the week of December 25-December 31, 2022 only three group sessions were documented in the client record. This is a repeat citation from the July 1, 2021 and May 11, 2022 licensing inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In order to abide by DDAP regulation, Clinical supervisor will work with case manager position to monitor regular attendance and accurately document instances where clients are absent from scheduled group and individual sessions with a start of August 1, 2023. In addition, clinical staff will be be re-trained in bimonthly group supervision starting August 1, 2023. Case manager will directly coordinate with clinicians on a daily basis to complete and document follow up calls for clients that have not been able to adhere to the prescribed frequency of scheduled sessions. |
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 a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in three out of three applicable records reviewed. The facility's policy and procedures manual states a case consultation must be completed " at least every 90 days. "Client #10 was admitted on January 25, 2023 and was still active at the time of the inspection. A case consultation was due to be completed on April 25, 2023, there was no documentation in the client record that this consultation was completed. Client #11 was admitted on November 4, 2022 and was still active at the time of the inspection. A case consultation was due to be completed February 4, 2023, the case consultation was not completed until February 13, 2023. Client #12 was admitted on September 26, 2022 and was discharged March 14, 2023. A case consultations was due to be completed December 26, 2022 , there was no documentation in the client record that this consultation was completed. This is a repeat citation from the May 11, 2022 licensing inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of August 1, 2023 the Clinical Supervisor and Site Coordinator will complete monthly chart audits with special attention paid to the completion of case consultations within the time lines that have been established by our policy and procedures. Site Coordinator will review case loads during regularly scheduled weekly group supervision to identify clients that are nearly due for consultation and ensure these are documented in the client chart within established timelines. Case consultations have been added to our transition bundles to more conveniently que clinicians when these consultations need to be documented. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on the review of patient records, the facility failed to comply with plans of correction approved by the Department.A plan of correction was submitted to the Department for inspections occurring on July 1, 2021 and May 11, 2022 addressing the requirement to ensure that clients are receiving counseling services according to their individual treatment plans for both partial and outpatient clients. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
We recognize an area of improvement to comply with the previously submitted POC regarding clients receiving counseling services according to their individual treatment plans for both partial and outpatient clients. We understand the necessity of consistently and accurately documenting this portion of our clients charts. Therefore we have invested resources into a new case manager position that will add an additional layer of support and accountability to this category or our documentation. In addition, starting July 1, 2023, the compliance and quality departments, in conjunction with clinical and operations leadership will be conducting consistent audits and meetings to ensure enforcement of the action plan. |