INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30 - July 1, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Licensure Programs. 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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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.
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Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in four out of fourteen client records review. The client records did not contain a consent to release information form for the funding source. Facility staff confirmed that billing had occurred. Client #2 was admitted on May 24, 2021 and was still active at the time of the inspection.Client #4 was admitted on December 29, 2020 and discharged on March 23, 2021. Client #5 was admitted on January 18, 2021 and discharged on June 2, 2021. Client #8 was admitted on April 29, 2021 and was still active at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will develop a training on 7/21/21 outlining established guidelines pertaining to the completion of informed and voluntary consent to release information with an emphasis on completing new and original consent forms when funding sources change within the course of treatment. All identified deficiencies will be correctly documented in clients chart no later than 7/27/21 |
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 partial hospitalization client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in four out of seven records reviewed.Client #8 was admitted on April 29, 2021 and was still active at the time of the inspection. A comprehensive treatment plan, dated May 4, 2021, indicated group sessions 5x/week and individual sessions 2x/week. During the week of May 30-June 5, group sessions occurred on June 1, 2 and 4 with a client no show on June 3, 2021. In addition, there was no documentation of individual sessions in the client's record. Client #10 was admitted on May 6, 2021 and was still active at the time of the inspection. A comprehensive treatment plan, dated May 10, 2021, indicated group sessions 5x/week and individual sessions 2x/week. During the week of May 30-June 5, group sessions occurred on June 2 and 3 with the client not showing on June 1 and 4, 2021. In addition, there was no documentation of individual sessions in the client's record.Client #12 was admitted on December 2, 2020 and discharged from the partial hospitalization program on April 24, 2021. The comprehensive treatment plan dated December 29, 2020 indicated weekly individual sessions. A treatment plan update, dated February 26, 2021, indicated individual sessions 2x/week. The client's first documented individual session occurred on April 20, 2021. Client #13 was admitted on February 10, 2021 and discharged from the partial hospitalization program on March 8, 2021. The comprehensive treatment plan dated February 19, 2021 indicated individual sessions 2x/week. The client had one individual session on February 8, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will develop training on 7/21/21 outlining established guidelines pertaining to the completion, tracking and execution of treatment plans for clients participating in partial hospitalization with an emphasis on accurately reflecting frequency of visits. All identified deficiencies will be correctly documented in client's charts no later than 7/27/21. |
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 outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in four out of seven records reviewed.Client #1 was admitted on May 17, 2021 and was still active at the time of the inspection. The comprehensive treatment plan, dated June 1, 2021, indicated group 4x/week and individual counseling monthly. There was no documentation of individual sessions in the client's record. Client #2 was admitted on May 24, 2021 and was still active at the time of the inspection. The comprehensive treatment plan, dated May 25, 2021, indicated group 4x/week and individual counseling monthly. During the week of May 30-June 5, group sessions occurred on June 1, 2 and 3. During the week of June 20-26, group sessions occurred on June 21, 23 and 25, 2021. In addition, there was no documentation of individual sessions in the client's record.Client #5 was admitted on January 18, 2021 and discharged on June 2, 2021. A case consultation dated March 15, 2021 indicated group sessions weekly. There was no documentation of a group session during the week of April 4-10, 2021.Client #7 was admitted on December 2, 2020 and discharged on March 10, 2021. A comprehensive treatment plan, dated December 4, 2020, indicated group sessions 5x/week. During week of December 6-12, group sessions occurred on December 9, 10 and 11, 2020. During week of January 10-16, group sessions occurred on January 11 and 14 with a client no show on January 13, 2021. During week of January 17-23, group session occurred on January 22 with a client no show on January 18, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will develop training on 7/21/21 outlining established guidelines pertaining to the completion, tracking and execution of treatment plans for clients participating in outpatient programming with an emphasis on accurately reflecting frequency of visits. All identified deficiencies will be correctly documented in client's charts no later than 7/27/21. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to display hours of operation in a manner which was visible to the public. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will develop a training on 7/21/21 reviewing the importance of not removing posted signs or replacing posted signs after cleaning. Hours of operation were immediately re-posted when the deficiency was identified on 6/30/21. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to display an emergency number in a manner which was visible to the public. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will develop a training on 7/21/21 reviewing the importance of not removing posted signs or replacing posted signs after cleaning. Emergency numbers were immediately re-posted when the deficiency was identified on 6/30/21. |