INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 22, 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.
|
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.
|
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 Two of two personnel records.
Findings:
Two 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 had CPR certifications in records #1 and 2. All staff's CPR certifications expired 10/08.
|
Plan of Correction
The two counselors who see clients at Mission New Life's First Church Clinic are now current in their CPR certification. Staff person #1 was recertified on February 21, 2009. Staff person #2 was recertified on January 31, 2009. To avoid lapsing coverage in the future, Mission New Life will stagger training at approximate six month intervals. Since the two counselors at Mission New Life First Church lose their first aid certification in October of this year, we will train the Project Director in October in both CPR and first aid. We will then train the other Counselor in June of 2010. In subsequent years we will split the trainings between January and July. We will select timing of training so that at least one person with current certification is always on site during normal hours of operation. The Project Director will be responsible for ensuring that this plan is carried out at Mission New Life First Church. |
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 the review of the facilities policy and procedure manual that was reviewed on January 21, 2009, the facility failed to provide a written procedure for staff and clients to follow in case of an emergency.
The findings include:
A review of the policy and procedure manual on January 29, 2009, revealed the facility failed to provide written procedures for staff and clients to follow in the event 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 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. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on the review of the facilities fire drill record, the facility failed to conduct unannounced fire drills at least once a month.
Findings:
The facility's fire drill record was reviewed on January 22, 2009. Fire drills were to be conducted at least once a month. The facility failed to document fire drills in May 2008, August 2008, September 2008, October 2008 and November 2008.
|
Plan of Correction
The Project Director will ensure that fire drills are conducted at least once a month at its First Church Clinic as required by State Regulations. |
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 the facilities 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 an annual report for the calender year 2007..
|
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)(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 the review of the facilities policy and procedure manual, the facility failed to document treatment models used by the project.
The findings include:
The policy and procedure manual was reviewed on January 21, 2009; the policy addressed treatment models that were 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 March 20, 2009 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 counselors.
|
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 the review of the facility's policy and procedure manual, the facility failed to provide current letters of agreement with referral sources.
The findings include:
Referral agreements were reviewed on January 21, 2009; the facility failed to provide updated letters of agreement with referral sources. The letters of agreement that were on file expired in 2005.
|
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 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 respective referral sources. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent form on two of two records reviewed.
The findings include:
Two records were reviewed on January 22, 2009. Informed and voluntary consent forms were required in two client records. Client record #2 did not have a consent to release form for the client's new parole officer, but documentation in the patient record revealed that correspondence had occurred. Client record #1 contained signed consent forms but there was no was documentation on the forms to include the name of the person or agency, the specific information being disclosed and the purpose of disclosure.
|
Plan of Correction
Mission New Life Client #2 was a "special offender" who had multiple Probation Officers. Mission New Life will ensure that all future disclosures of client information will only be made to persons for which the client has signed a release naming the person to whom he/she is granting permission to disclose information. Mission New Life Client #1 will be asked to sign new releases which document the name of the person and agency as well as the specific information to be disclosed and the purpose of the disclosure. The Project Director will review client records in the future to ensure that all required releases are obtained and properly completed. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
|
Observations
Based on the review of client records, the facility failed to document that client rights were reviewed with the client in one of two records.
The findings:
The client records were reviewed on January 22, 2009. Documentation that identified client rights were reviewed with the client were required in two client records. Client record #1 did not have any documentation that identified client was informed of their client rights.
|
Plan of Correction
Client #1 was first admitted to Mission New Life on May 16, 2006 prior to incarceration in Lancaster Prison on June 10, 2006. He was released from Lancaster County Prison and readmitted on June 22, 2006. He remained in treatment until November 20, 2006 when he was incarcerated again in Lancaster County Prison. Upon release from Lancaster County Prison, Client #1 was readmitted to Mission New Life on January 4, 2007 and remained in treatment until May 4, 2007 when he was discharged for non-compliance. Client #1 served more time in Lancaster County Prison, but upon release was again admitted to Mission New Life on August 18, 2008. He was discharged on November 11, 2008 having admitted himself to another facility for inpatient treatment. Upon release from two weeks of inpatient treatment, Client #1 was readmitted to Mission New Life on December 19, 2008. Given the short period that the client was not an active Mission New Life client, the usual intake/orientation documentation was omitted for the fourth readmission. In the future, all intake/orientation documentation will be reviewed with the client and made a part of his/her client record no matter how many times he/she has been in treatment with us. |
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.
|
Observations
Based on the review of the facility's policy and procedure manual, the facility failed to include a written plan that addressed client intake and admission criteria.
The findings include:
The policy and procedure manual was reviewed on January 21, 2009. The facility failed to develop a written plan that addressed the facility's criteria for admission.
|
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 its 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. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
|
Observations
Based on the review of client records, the facility failed to include documentation of the client's criteria for admission, treatment, completion of treatment and discharge procedures in one of two patient records.
The findings:
Two records were reviewed on January 22, 2009. Documentatio of intake procedures were required in two client records. Client record #1 did not show documentation of the intake and admission procedures.
|
Plan of Correction
Client #1 was admitted to Mission New Life for the fourth time on August 19, 2008 after serving fourteen months in Lancaster County Prison. The client last showed for treatment on November 12, 2008. Without informing Mission New Life Client #1 admitted himself for two weeks of inpatient treatment. Client #1's counselor was caught off guard and neglected to follow Mission New Life policy and procedures when Client #1 sought readmission. Consequently, required intake and admission procedures were not followed. To correct this deficiency, Client #1's counselor will complete all intake procedures as required by State standards and Mission New Life Policy & Procedures and make all required documentation a part of Client #1's record. For the next three months, the Project Director will review open client charts weekly to insure that all intake and admission procedures are followed and properly documented. After three months, the Project Director will randomly review all open client charts at least quarterly to ensure that State standards and Mission New Life Policy is met. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
|
Observations
Based on the review of client records, the facility failed to include documentation of the client's orientation in one of two client records.
The findings:
Two records were reviewed on January 22, 2009. Client orientations were required in two client records. Client record #1 did not contain documentation that the client received program orientation.
|
Plan of Correction
Client #1 was admitted to Mission New Life for the fourth time on August 19, 2008 after serving fourteen months in Lancaster County Prison. The client last showed for treatment on November 12, 2008. Without informing Mission New Life Client #1 admitted himself for two weeks of inpatient treatment. Client #1's counselor was caught off guard and neglected to follow Mission New Life policy and procedures when Client #1 sought readmission. Consequently, required intake and admission procedures were not followed. To correct this deficiency, Client #1's counselor will review orientation documents with Client #1 and make all required documentation a part of Client #1's record. For the next three months, the Project Director will review open client charts weekly to insure that all intake and admission procedures are followed and properly documented. After three months, the Project Director will randomly review all open client charts at least quarterly to ensure that State standards and Mission New Life Policy is met. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
|
Observations
Based on the review of client records, the facility failed to include documentation of the client's orientation in one of two client records.
The findings:
Two records were reviewed on January 22, 2009. Client orientations are required in two client records. Client record #1 did not provide documentation that they received orientation pertaining to the facility's office hours.
|
Plan of Correction
Client #1 was admitted to Mission New Life for the fourth time on August 19, 2008 after serving fourteen months in Lancaster County Prison. The client last showed for treatment on November 12, 2008. Without informing Mission New Life Client #1 admitted himself for two weeks of inpatient treatment. Client #1's counselor was caught off guard and neglected to follow Mission New Life policy and procedures when Client #1 sought readmission. Consequently, required intake and admission procedures were not followed. To correct this deficiency, Client #1's counselor will review hours of operation with Client #1 and make required documentation a part of Client #1's record. For the next three months, the Project Director will review open client charts weekly to insure that all intake and admission procedures are followed and properly documented. After three months, the Project Director will randomly review all open client charts at least quarterly to ensure that State standards and Mission New Life Policy is met. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
|
Observations
Based on the review of client records, the facility failed to include documentation of the client's orientation in one of two client records.
The findings:
Two records were reviewed on January 22, 2009. Client orientations were required in two client records. Client record #1 did not contain documentation that the patient received program orientation that included the facility's fee schedule.
|
Plan of Correction
Client #1 was admitted to Mission New Life for the fourth time on August 19, 2008 after serving fourteen months in Lancaster County Prison. The client last showed for treatment on November 12, 2008. Without informing Mission New Life Client #1 admitted himself for two weeks of inpatient treatment. Client #1's counselor was caught off guard and neglected to follow Mission New Life policy and procedures when Client #1 sought readmission. Consequently, required intake and admission procedures were not followed. To correct this deficiency, Client #1's counselor will review Mission New Life's fee schedule with Client #1 and make required documentation a part of Client #1's record. For the next three months, the Project Director will review open client charts weekly to insure that all intake and admission procedures are followed and properly documented. After three months, the Project Director will randomly review all open client charts at least quarterly to ensure that State standards and Mission New Life Policy is met. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
|
Observations
Based on the review of client records, the facility failed to include documentation of the client's orientation in one of two client records.
The findings:
Two records were reviewed on January 22, 2009. Client orientations are required in two client records. Client record #1 failed to provide documentation that they received orientation regarding services provided by the the facility.
|
Plan of Correction
Client #1 was admitted to Mission New Life for the fourth time on August 19, 2008 after serving fourteen months in Lancaster County Prison. The client last showed for treatment on November 12, 2008. Without informing Mission New Life Client #1 admitted himself for two weeks of inpatient treatment. Client #1's counselor was caught off guard and neglected to follow Mission New Life policy and procedures when Client #1 sought readmission. Consequently, required intake and admission procedures were not followed. To correct this deficiency, Client #1's counselor will review services provided by Mission New Life with Client #1 and make required documentation a part of Client #1's record. For the next three months, the Project Director will review open client charts weekly to insure that all intake and admission procedures are followed and properly documented. After three months, the Project Director will randomly review all open client charts at least quarterly to ensure that State standards and Mission New Life Policy is met. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on the review of client records, the facility failed to include documentation of the client's medical history in one of two records.
The findings:
Two records were reviewed on January 22, 2009. Client medical histories are required in two client records. Client record #1 did not show documentation of their medical history.
|
Plan of Correction
Client #1 was admitted to Mission New Life for the fourth time on August 19, 2008 after serving fourteen months in Lancaster County Prison. The client last showed for treatment on November 12, 2008. Without informing Mission New Life Client #1 admitted himself for two weeks of inpatient treatment. Client #1's counselor was caught off guard and neglected to follow Mission New Life policy and procedures when Client #1 sought readmission. Consequently, required intake and admission procedures were not followed. To correct this deficiency, Client #1's counselor will review changes in Client #1's medical history since his previous admission in August and make required documentation a part of Client #1's record. For the next three months, the Project Director will review open client charts weekly to insure that all intake and admission procedures are followed and properly documented. After three months, the Project Director will randomly review all open client charts at least quarterly to ensure that State standards and Mission New Life Policy is met. |
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 the review of client records, the facility failed to include documentation of the client's drug and/or alcohol history in one of two records.
The findings:
Two records were reviewed on January 22, 2009. Client drug and/or alcohol histories were required in two client records. Client record #1 did not show documentation of their drug and/or alcohol history.
|
Plan of Correction
Client #1 was admitted to Mission New Life for the fourth time on August 19, 2008 after serving fourteen months in Lancaster County Prison. The client last showed for treatment on November 12, 2008. Without informing Mission New Life Client #1 admitted himself for two weeks of inpatient treatment. Client #1's counselor was caught off guard and neglected to follow Mission New Life policy and procedures when Client #1 sought readmission. Consequently, required intake and admission procedures were not followed. While Client #1's counselor did review changes in Client #1's drug and alcohol history since his admission in August, these changes were not documented in Client #1's client history. Client #1's counselor will make required documentation a part of Client #1's record. For the next three months, the Project Director will review open client charts weekly to insure that all intake and admission procedures are followed and properly documented. After three months, the Project Director will randomly review all open client charts at least quarterly to ensure that State standards and Mission New Life Policy is met. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on the review of client records, the facility failed to include documentation of the client's consent to treatment in one of two records.
The findings:
Two records were reviewed on January 22, 2009. Consent to treatment forms were required in two client records. Client record #1 did not include documentation that indicated they had consented to treatment.
|
Plan of Correction
Client #1 was admitted to Mission New Life for the fourth time on August 19, 2008 after serving fourteen months in Lancaster County Prison. The client last showed for treatment on November 12, 2008. Without informing Mission New Life Client #1 admitted himself for two weeks of inpatient treatment. Client #1's counselor was caught off guard and neglected to follow Mission New Life policy and procedures when Client #1 sought readmission. Consequently, required intake and admission procedures were not followed. Client #1's counselor will have Client #1's sign a new Consent to Treatment and make required documentation a part of Client #1's record. For the next three months, the Project Director will review open client charts weekly to insure that all intake and admission procedures are followed and properly documented. After three months, the Project Director will randomly review all open client charts at least quarterly to ensure that State standards and Mission New Life Policy is met. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on the review of client records, the facility failed to include documentation of the client's preliminary treatment and rehabilitation plan in one of two records.
The findings include:
Two records were reviewed on January 22, 2009. Preliminary treatment and rehabilitation plans were required in two client records. Client record #1 failed to include documentation of the client's preliminary treatment plan.
|
Plan of Correction
Client #1 was admitted to Mission New Life for the fourth time on August 19, 2008 after serving fourteen months in Lancaster County Prison. The client last showed for treatment on November 12, 2008. Without informing Mission New Life Client #1 admitted himself for two weeks of inpatient treatment. Client #1's counselor was caught off guard and neglected to follow Mission New Life policy and procedures when Client #1 sought readmission. Consequently, required intake and admission procedures were not followed. Client #1's counselor developed a preliminary treatment plan with Client #1, but failed to document the plan in Client #1's record. Client #1's counselor will document Client #1's preliminary treatment plan and make it a part of Client #1's record. For the next three months, the Project Director will review open client charts weekly to insure that all intake and admission procedures are followed and properly documented. After three months, the Project Director will randomly review all open client charts at least quarterly to ensure that State standards and Mission New Life Policy is met. |
709.92(a) 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:
|
Observations
Based on the review of client records, the facility failed to include documentation of the client's comprehensive treatment plan in one of two records.
The findings include:
Two records were reviewed on January 22, 2009. Comprehensive treatment plans were required in two client records. Client record #1 failed to provide documentation of the client's comprehensive treatment plan.
|
Plan of Correction
Client #1 was admitted to Mission New Life for the fourth time on August 19, 2008 after serving fourteen months in Lancaster County Prison. The client last showed for treatment on November 12, 2008. Without informing Mission New Life Client #1 admitted himself for two weeks of inpatient treatment. Client #1's counselor was caught off guard and neglected to follow Mission New Life policy and procedures when Client #1 sought readmission. Consequently, a new treatment and rehabilitation plan was not developed until seven sessions after readmission. In the future, the Project Director will insure that all intake and admission procedures are followed and properly documented for each admission and readmission including the development of a treatment and rehabilitation plan. |
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.
|
Observations
Based on the review of client records, the facility failed to document progress notes in one of two client records.
Findings:
Two client records were reviewed on January 22, 2009. Individual progress notes were required in two client records. The client was admitted on 10/7/07 and the record of service indicated that the client's last session was 10/4/08, however the last progress note documented in the client's record was dated 5/1/08.
|
Plan of Correction
Progress notes were made after each session. However, they were not typed in final form and placed in the client's chart. In the future, the Project Director will insure that all progress notes are prepared in the required format and a copy made a part of the client record.
|
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.
|
Observations
Based on a review of client records on January 22, 2009, the facility failed to document complete case consultation notes in one of two client records.
Findings:
Two client records were reviewed. Case consultations were required in one client records. Case consultations note in record #2 was done late. Client record #2 was admitted on 10/11/07 and the last case consultation was completed on 2/6/08, their case consultation notes should have also been completed by 5/11/08, 8/11/08 and 11/1108. Also, in client records #2 there was only one person present, case consultations are to be done by two or more staff.
|
Plan of Correction
In the future, case consultations and case consultation notes will be done according to Mission New Life's Policy and Procedures and according to State Standards. Case consultation notes will be reviewed with at least one other person who will sign and date the case consultation note on the day the consultation is held. The Project Director will monitor all case consultations at the Mission New Life First Church Clinic. |