INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on July 5, 2007 through July 6, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on July 31, 2007.
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Plan of Correction
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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
The facility failed complete an annual report.
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Plan of Correction
Activities and accomplishments and a financial statement as well as names of officers of Mission New Life were available for Year 2006. However, health issues and workload prevented the Project Director from compiling this data into an annual report for Year 2006. The Project Director will compile available data into a Year 2006 Annual Report. Specifically, the Project Director will reformat into an annual report, publish the report, distribute the report to Mission New Life advisors and other interested parties, and publishe a notice in the Lancaster Newspapers that Mission New Life's Year 2006 Annual Report is available to the public for review at Mission New Life's clinic at 39 West Vine Street or that a copy of Mission New Life's Year 2006 Annual Report can be obtained by sending a written request to Mission New Life's administrative office at 203 Crescent Drive in Hershey. Regarding future annual reports, the Project Director will train the Administratie Assistant to compile data required for Mission New Life's annual report on a month-to-month basis. She will be accountable for providing the Project Director with a draft annual report within three months of the end of the report year. The Project Director will be accountable for the acutal publication, distribution, and notification of avaiability of each annual report. If for any reason the Project Dirctor is incapacitated, the Associate Director will be held accountable for the publication, distribution, and notification of avaiability of the relevant annual report. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
The facility failed to have a written agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage. The written agreement on file had an expiration date of 2005.
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Plan of Correction
The Project Director failed to renew Mission New Life's agreement with Lancaster General Hospital for 24-hour psychiatric and medical coverage. The Project Director will seek an updated agreement with Lancaster General Hospital for 24-hour psychiatric and medical coverage. To ensure that written agreements for 24-hour psychiatric snd medical coverage are maintained in the future, Mission New Life will develop a tickle system to warn of approaching expiration dates. Mission New Life will hold the Administrative Assistant accountable for monitoring the tickle system, preparing a new agreement two months prior to expiration, and submitting to the Project Director for execution and forwarding to Lancaster General Hospital for execution on their part and return to Mission New Life our records. |
705.1 (2) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
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Observations
The facility failed to provide a Certificate of Occupancy from the Department of Labor and Industry or its local equivalent.
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Plan of Correction
The Certificate of Occupancy for Mission New Life's First Church Clinic was misfiled and not available when the Licensing Specialist visited the facility. The Project Director found the Certificate of Occupancy after the visit and provided a copy to the Department of Health on July 13, 2007. The Project Director will review Mission New Life filing systems to ensure that all documentation is properly filed and readily retrievable. In the future, the Project Director will make sure that all documentation is avialable for the Licensing Specialist prior to his/her visit. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room. The window in the door to the counseling room was not covered for privacy.
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Plan of Correction
First United Methodist Church provides one of its Sunday School classrooms to Mission New Life to use for counseling. For the safety of its own staff, members, and visitors, the Church uses doors with small (8"x 8") observation windows. When Mission New Life provides drug and alcohol treatment services to a client or perspective client, the window compromises the client's privacy. In the future, when providing drug and alcohol treatment services, Mission New Life staff will cover the observation window to ensure privacy during counseling sessions. |
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
The facility failed to provide written procedures for staff and clients to follow in case of an emergency. The facility's policy did not address internal versus external disasters and did not include the evacuation to a safe location.
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Plan of Correction
The First United Methodist Church hosts Mission New Life in its church school building. While Mission New Life relies on the Church's disaster plan, Mission New does trains its own staff in use of fire extinguishers and conducts its own fire drills, using evacuation routes and evacuation procedures specified by the Church. Mission New Life's Project Director will determine both the Church's and the City's disaster plans, assess how they relate to Mission New Life's operations, and develop a specific Disaster Plan for Mission New Life, which addresses both internal and external disasters. The Project Director will train Staff regarding emergency procedures including chain of command, responsibility, and accountability. The Project Director will incorporate the associated policy, procedures, and plans into Mission New Life's Policy & Procedures Manual. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
The facility failed to follow their written policy to have all clients receive a physical examination. Physical examinations were missing in two of three client records reviewed, #1 and 2. A review of organ systems was missing from the physical examination in client record #3.
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Plan of Correction
Mission New Life's Policy & Procedure regarding physical examinations requires clarification. Mission New Life's policy does not require all clients to obtain a physical examination. The Project Director will revise Mission New Life's Policy & Procedure regarding Physical Examinations, review with Staff, and incorporate a revised policy statement into Mission New Life's Policy & Procedures Manual. |
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
The facility failed to document a complete psychosocial evaluation in one of three client records reviewed, #1. The client's presenting and underlying problems and coping mechanisms were not identified and simply noted as drug/alcohol use.
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Plan of Correction
The Project Director/Counselor did not complete a psychosocial summary for Client #1. This was an oversight. Mission New Life's intake and admission procedure requires presentation and processing of 55 pages of documentation including 30 forms that require client and witness dated signatures. To complete the evaluation and assessment, the counselor must process a 12-page client history questionnaire. The Counselor then summarizes all this with a Pennsylvania Client Placement Criteria summary sheet, a Case Consultation Note, and a Psychosocial Summary. We find this very difficult to do in three hours of face-to-face client contact and within seven days. Hence, we use an abbreviated Psychosocial Summary form (2 pages) in an effort to save time and energy. In the rush to get everything done on time, Mission New Life counselors some-times do not provide sufficient detail in a client's psychosocial summary. The Project Director will meet with Mission New Life clinical staff, review the current Psychosocial Summary form, assess additional data required to document a Psychosocial Summary that meets Department of Health Standards, revise the current form, and incorporate it into Mission New Life's Policy & Procedures Manual. The Project Director/Counselor will be accountable for implementing a revised psychosocial summary form for the Mission New Life - First Church Clinic and completing it as part of the each future client's evaluation/assessment phase of treatment. |
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:
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Observations
The facility failed to develop an individual treatment plan in one of three client records reviewed, #1. The individual treatment plan was missing.
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Plan of Correction
When Client #1 rejected Outpatient Drug and Treatment, Mission New Life offered to mentor him through Suboxone treatment. The client accepted mentoring outside the Mission New Life Clinic. In retrospect, Mission New Life should have completed its assessment of Client #1, discharged him, and made it clear in the Discharge Summary that the counselor would discontinue drug and alcohol treatment and proceed with mentoring. This is a lesson learned. The Project Director will review the case with Staff, develop procedures to use in such cases in the future, and incorporate an appropriate Policy & Procedure into Mission New Life's Policy & Procedures manual. |
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
The facility failed to document follow-up information in one of one client records reviewed, #3.
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Plan of Correction
Mission New Life' current policy is to follow up with clients at 30 , 90, 180, and 365 says after discharge. Mission New Life has not been able to adhere to this policy. The Project Director will review the current Policy & Procedure with staff, develop a more realistic Policy & Procedure, and incorporate into Mission New Life's Policy & Procedures Manual. The Clinical Director will monitor future cases to ensure follow-up of discharged clients. |
704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
The plan documenting the qualifications and training of staff was not presented at the time of the site visit.
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Plan of Correction
The Project Director failed to complete staff qualifications and training documentation prior to the Licensing Specialist's site visit. The Project Director completed documentation during the site visit and provided completed documentation to the Licensing Specialist during her visit. In the future, the Project Director will carefully read instruction regarding preparation for site visits and make sure that all required paperwork is completed prior to Licensing Specialist's visit.
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