INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 3, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Open Door Counseling at Mazzoni Center 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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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The organization requested and was granted an extension from the IRS for tax filing due to change in Executive Financial Officer role. The program believed this extension from the IRS was sufficient. In hindsight, the program now understands its responsibility to inform DDAP in writing of this request. The current audit is expected to be completed by June 1, 2023. In the future, the Program Director will inform DDAP in writing of any significant change related to financial audit. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel records contained an annual written performance evaluation that was reviewed and signed by the employee in three of four applicable personnel records reviewed.
Employee #2 was hired as the Facility Director on June 1, 2020 and is still current in that position. The last annual written performance evaluation documented was dated September 30, 2021.
Employee #3 was hired as the Clinical Supervisor on October 19, 2020 and is still current in that position. The last annual written performance evaluation documented was dated September 28, 2021.
Employee #7 was hired as a counselor on September 15, 2021 and is still current in that position. The last annual written performance evaluation documented was dated September 29, 2021.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Mazzoni Center was in the midst of collective bargaining with our labor union. Personnel evaluation format and schedule was part of the negotiation process, resulting in a delay in staff evaluations being completed. The next regularly scheduled time for evaluations will begin December 1, 2023 based on policy. Director will review all staff evaluations and approve by December 31, 2023 and submit to HR. all future evaluations will be completed on an annual cycle no later than December 31 of that calendar year. Director will monitor for ongoing compliance.
The new format schedule has been agreed upon and moving forward, staff evaluations will be completed for all program staff on an annual basis. Evaluations will be completed by December 31, 2023. Record of evaluations will be kept by HR. Program Director will monitor timely completion of all staff evaluations on an annual basis. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of seven client records, the facility failed to document that the client was given the opportunity to request reconsideration of a decision terminating treatment in one of one applicable record reviewed.
Client #1 was admitted on October 4, 2022 and was administratively discharged on February 14, 2023. There was no documentation in the client record that the client was given the opportunity to request reconsideration of a decision terminating treatment.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon review of the record of Client #1, program management considered methods to improve communication to clients who are administratively discharged. Correspondence will include information providing an opportunity to request reconsideration of termination decision. Staff were reminded to include this information in correspondence, and Clinical Supervisor and Assist. Director will review all administrative discharges closely to ensure this information is included in correspondence with clients. |
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 ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in two of five applicable client records reviewed.
Client #6 was admitted on July 8, 2022 and was active at the time of the inspection. A treatment plan update was completed on November 11, 2022, and another treatment plan update was due no later than January 11, 2023; however, the treatment plan update was not completed until February 24, 2023.
Client #7 was admitted on June 3, 2022 and was active at the time of the inspection. A treatment plan update was completed on September 9, 2022, and the next update was due no later than November 9, 2022; however, the treatment plan update was not completed until December 8, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At a meeting with staff on 4/11/2023, reviewed with staff expectations for Treatment Plan completion and quality. Staff understand Treatment Plans are to be updated every 60 days. Staff expressed understanding of this regulation and will improve timely completion of plans moving forward. Asst Director and Clinical Supervisor will create schedules of due dates to help monitor timely completion. Program Director will monitor on an ongoing basis to ensure compliance. |
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 counseling services were provided according to the individual treatment and rehabilitation plans in three of six applicable records reviewed.
Client #2 was admitted on July 26, 2022 and was discharged on October 20, 2022. The treatment and rehabilitation plan completed on August 3, 2022, indicated that the client was to receive two group sessions per week; however, the record only contained documentation of one group session during the weeks of August 15, 2022 and August 22, 2022.
Client #3 was admitted on September 6, 2022 and was discharged on December 15, 2022. The treatment plan completed on October 3, 2022, indicated that the client was to receive one individual session per week; however, the record did not contain documentation that individual sessions were offered between September 28, 2022 and October 24, 2022.
Client #6 was admitted on July 8, 2022 and was active at the time of the inspection. The treatment plan completed on November 11, 2022, indicated that the client was to receive one individual session per week; however, the record did not contain documentation that individual sessions were offered between December 9, 2022 and December 22, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This issue was examined further and determined that quality improvement is based on better documentation of obstacles and barriers to meeting the treatment and rehabilitation plan outline. For example, when a group or individual session is not held, the reason for not holding the session and subsequent outreach needs to be clearly documented. Staff were advised on this at a team meeting on 4/11/23. Asst. Program Director and Clinical Supervisor will monitor closely, and Program Director will ensure compliance with random chart inspections. |
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 ensure a complete client record included information relative to the client's involvement with the project that included case consultation information in three of four applicable records reviewed.
Client #1 was admitted on October 4, 2022 and was discharged on February 14, 2023. There was no documentation of a case consultation in the record.
Client #2 was admitted on July 26, 2022 and was discharged on October 20, 2022. There was no documentation of a case consultation in the record.
Client #4 was admitted on January 28, 2021 and was discharged on November 28, 2022. There was no documentation of a case consultation in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program will keep regular case consultation notes in the EMR chart to meet compliance with this regulation. Case consultation will continue to occur on a quarterly basis for clients enrolled less than one year, and at least once annually for those enrolled over one year. Asst. Director and Clinical Supervisor understand their responsibility moving forward. Program Director will monitor for compliance ongoing. |
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 ensure a complete client record included information relative to the client's involvement with the project that included follow-up information within seven days of discharge, per facility policy, in four of four applicable records reviewed.
Client #1 was admitted on October 4, 2022 and was discharged on February 14, 2023. There was no documentation of follow-up information in the record.
Client #2 was admitted on July 26, 2022 and was discharged on October 20, 2022. There was no documentation of follow-up information in the record.
Client #3 was admitted on September 6, 2022 and was discharged on December 15, 2022. There was no documentation of follow-up information in the record.
Client #4 was admitted on January 28, 2021 and was discharged on November 28, 2022. There was no documentation of follow-up information in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staffing challenges created inconsistency in meeting this regulation. Program management met to address ways to ensure compliance with the follow-up regulation. Staff will be assigned to make a follow-up attempt within 7 days of discharge. Attempts will be clearly documented in the record. Asst. Director and Clinical Supervisor are responsible to review charts for compliance. Program Director will monitor for ongoing compliance. |