INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 2017 by staff from the Division of Drug and Alcohol 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
One personnel record was reviewed for the clinical supervisor position on June 14, 2017. For employee record # 3, the facility failed to provide documentation verifying that the employee participated in documented monthly meetings for the first 6 months of employment in the clinical supervisor position.
Employee # 3 was initially hired by the project on 8/24/09 and assumed the clinical supervisor position on 4/21/16. The employee's record did not contain documentation of monthly meetings with their supervisor/s during the employee's first 6 months of employment in the clinical supervisor position.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee had attended Clinical Supervision Training through DDAP on 10/28/16 and had also since time of promotion participated in weekly supervision meetings which had not been documented as needed. Leadership staff has been updated as to full requirements for clinical staff promotions and need for supervision documentation will be incorporated into any future promotions of clinical supervisors. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Seven personnel records were reviewed on June 14, 2017. The facility failed to provide documentation of required HIV/AIDS training for employee record # 5.
Employee # 5 was hired by the facility on 5/16/16 as a counselor. The employee was required to complete HIV/AIDS training by no later than 5/16/17. The facility failed to provide documentation of this training.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Initial training scheduled for this staff was in March but was cancelled due to inclement weather. Mazzitti and Sullivan continues to work to develop a more effective onboarding process and has made recent changes to new hire paperwork and trainings in order to more fully ensure overall compliance with mandatory trainings. Supervisor reports that employee #5 is currently scheduled to attend and complete this training on 7/26/17.Clinical Director will be responsible for overall oversight and monitoring compliance ongoing with this standard. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
A physical plant inspection was conducted on June 16, 2017. A space heater that was not permanently mounted or installed was observed in an administrative office located on the 3rd floor of the facility.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff at this location has been re-trained on space heater requirements and space heater that was observed during physical plant inspection has been removed. Clinical Director responsible for this office will be responsible for ensuring corrective action is implemented as well as ongoing oversight of compliance with this standard. |
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
Seven client records were reviewed on June 16, 2017. The facility failed to obtain an informed and voluntary consent which documented the purpose of the disclosure for client record # 5. The facility also failed to obtain an informed and voluntary consent where consent was applicable for client record # 2.
Client # 2 was admitted into treatment on 11/21/16 and was still active in treatment. Documentation in the client's record indicated that the facility forwarded a letter to a county probation officer on 2/9/17, reporting the client's presence in treatment. A consent to release information to this probation officer was signed and dated by the client on a later date, specifically on 2/13/17. In addition, documentation in the client's record indicated that the facility forwarded a letter to a probation officer for a different county on 3/23/17. A consent to release information to this probation officer was signed and dated by the client on a later date, specifically on 3/27/17. Lastly, a consent to release information to the client's treatment funding source was not documented in the client's record.
Client # 5 was admitted into treatment on 12/10/16 and was discharged on 3/10/17. A consent to release information to county probation office, signed and dated 3/2/17, did not specify the purpose of disclosure. Documention in the client's record indicated that the facility forwarded a letter to the probation office on 3/8/17, reporting the client's discharge from the facility.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Mazzitti and Sullivan has recently moved to EMR which will allow for greater compliance with Release of Information. Templates will ensure that all needed areas are marked and will also alert staff if they overlook a needed release for a collateral contact. Staff has received in depth training related to EMR and continues to receive support and training as needed.
In regards to Client #2, assessment bundle will address this deficiency as forms will show as needing to be completed related to release of information. ROI for treatment funding source was obtained for this client as needed. Clinical Director will be responsible for ensuring corrective actions take place as well as ongoing oversight of compliance with this standard. Supervisory follow up with occur through regular chart audits as well as auditing made possible through EHR. |
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
Seven client records were reviewed on June 16, 2017. The facility failed to document a complete psychosocial evaluation for client records # 2, 4, and 7,
Client # 2 was admitted into treatment on 11/21/16 and was still active in treatment. A psychosocial evaluation was completed for the client on 11/21/16. This psychosocial evaluation did not document an evaluation of the following areas specified on the standardized form used by the facility: composite picture, client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and counselor conclusions/impressions.
Client # 4 was admitted into treatment on 7/13/16 and was still active in treatment. A psychosocial evaluation was not documented in the client's record.
Client # 7 was admitted into treatment on 7/15/16 and was discharged on 1/12/17. A psychosocial evaluation was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff has been re-trained on process of fully completing psychosocial evaluation which is covered during new hire training and historically was reviewed during course of auditing process of charts. With recent transition to EMR, EMR will have daily report called "My Alerts" which will indicate for clinical staff and supervisory all needed documentation for that time period and any delinquent forms or documentation. Clinical supervision reviews MY Alerts at minimum twice weekly and all clinical staff is required to review their reports on daily basis. This process was trained and implemented in late June, early response has been positive and staff has been compliant in following expected processes. EMR will also allow for significantly increased transparency with chart reviews by supervisors.
EMR will not allow for psychsocial evaluation to be signed and submitted without all areas being completed in form and from assessment to include: composite picture, client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and counselor conclusions/impressions. All required sections are listed in evaluation bundle and clinical staff is able to view which sections they have completed and which still need to be done. Psychsocials are required to be completed within 24 hours of evaluation being done, staff are reviewed for compliance with this measure. Clinical Director will be responsible for ensuring these corrections are implemented and continued oversight and compliance with this standard. |
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
Seven client records were reviewed on June 16, 2017. The facility failed to document that an individual treatment and rehabilitation plan was developed with the client for client records # 2, 4, and 5. In addition, the facility failed to document the type and/or frequency of treatment services on the individual treatment and rehabilitation plan for client records # 3 and 6. Lastly, the individual treatment and rehabilitation plan did not include the signature of the counselor for client record # 4.
Client # 2 was admitted into treatment on 11/21/16 and was still active in treatment. The individual treatment and rehabilitation plan documented in the client's record was completed on 11/21/16. The client's record did not include documentation that the treatment plan was developed with the client.
Client # 3 was admitted into treatment on 2/17/17 and was still active in treatment. The individual treatment and rehabilitation plan documented in the client's record, completed on 2/17/17, did not specify the type and frequency of treatment services.
Client # 4 was admitted into treatment on 7/13/16 and was still active in treatment. The individual treatment and rehabilitation plan documented in the client's record was completed on 7/13/16. The client's record did not include documentation that the treatment plan was developed with the client. In addition, the same treatment plan did not include the signature of the counselor.
Client # 5 was admitted into treatment on 12/10/16 and was discharged on 3/10/17. The individual treatment and rehabilitation plan documented in the client's record was completed on 12/16/16. The client's record did not include documentation that the treatment plan was developed with the client.
Client # 6 was admitted into treatment on 10/24/16 and was discharged on 1/30/17. The individual treatment and rehabilitation plan documented in the client's record, completed on 10/24/16, did not specify the type and frequency of treatment services.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Electronic health record will use BASIS-24 at assessment and at treatment updates in order to assess response to treatment and gauge treatment planning process and treatment efficacy overall. EMR requires signature of client and counselor for tx plan to be submitted to supervisor which will assist in prompting staff to document client participation in development of treatment plan. Further, there is a section that elicits clients goals for treatment in their own words. Lastly, frequency of treatment is another needed aspect of EMR tx plan. Review of needs to tx plans has been scheduled during weekly staff meetings in order to reinforce staffs recognition of needed tx planning. Clinical Directors assigned to each office are required to review and sign off on treatment plans in EHR which will allow for verification that treatment plans are completed in compliance with this standard. Clinical Directors will be responsible for any needed corrective actions and also ongoing compliance as well as identifying additional supports such as incorporating reviews of tx plans into individual supervision or group supervision sessions. Supervisory follow up with occur in the following ways: Clinical Directors will review treatment plans prior to signing off on completion, any needed changes will be noted and passed along to clinical staff. Clinical Director will review progress through My Alerts and will be able to view directly when changes have been made through EMR. If there is a need to increase support or follow up, treatment planning will become regular part of supervision until such time as staff member is able to show needed proficiency in treatment planning documentation. |
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
Seven client records were reviewed on June 16, 2017. The facility failed to document a treatment plan update at least every 60 days for client records # 1, 2, 3, 4, and 7.
Client # 1 was admitted into treatment on 1/6/17 and was still active in treatment. A comprehensive treatment plan was completed for the client on 1/17/17. A treatment plan update was due to be completed for the client by 3/17/17, and one was not documented in the client's record.
Client # 2 was admitted into treatment on 11/21/16 and was still active in treatment. The last treatment plan update documented in the client's record was completed on 3/21/17. A subsequent treatment plan update was due to be completed for the client by 5/21/17, and one was not documented in the client's record.
Client # 3 was admitted into treatment on 2/17/17 and was still active in treatment. The last treatment plan update documented in the client's record was completed on 3/17/17. A subsequent treatment plan update was due to be completed for the client by 5/17/17 and one was not documented in the client's record.
Client # 4 was admitted into treatment on 7/13/16 and was still active in treatment. A comprehensive treatment plan was completed for the client on 7/13/16. A treatment plan update was due to be completed for the client by 9/13/16, and one was not documented in the client's record.
Client # 7 was admitted into treatment on 7/15/16 and was discharged on 1/12/17. The last treatment plan update documented in the client's record was completed on 9/21/16. A subsequent treatment plan update was due to be completed for the client by 11/21/16, and one was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
EMR will have daily report called "My Alerts" which will indicate for clinical staff and supervisory all needed documentation for that time period and any delinquent forms or documentation. Clinical supervision reviews MY Alerts at minimum twice weekly and all clinical staff is required to review their reports on daily basis. This process was trained and implemented in late June, early response has been positive and staff has been compliant in following expected processes. Clinical Directors are required to review and sign tx plans, they also have ability to run reports to verify any delinquent tx plans and will be able to counsel staff and or incorporate tx planning needs into supervisory sessions. Clinical Directors are responsible of implementing corrective actions as well as overall oversight with this standard. |
709.93(a) 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:
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Observations
Seven client records were reviewed on June 16, 2017. The facility failed to ensure that a complete client record was documented for client records # 1, 2, 5, and 7.
Client # 1 was admitted into treatment on 1/6/17 and was still active in treatment. A review of the client's record determined that the facility did not provide counseling services to the client during the period of 2/10/17 - 5/29/17. Facility staff reported that the lapse in treatment was due to the client's admission into inpatient rehabilitation. The facility failed to document a case consultation note concerning the client's treatment status.
Client # 2 was admitted into treatment on 11/21/16 and was still identified as active in treatment. A review of the client's record determined that the client last received counseling services on 3/27/17. Facility staff reported that the client was no longer an active client and should have been discharged from treatment. A case consultation note and a discharge summary were not documented in the client's record.
Client # 5 was admitted into treatment on 12/10/16 and was discharged on 3/10/17. Follow-up information was not documented in the client's record.
Client # 7 was admitted into treatment on 7/15/16 and was discharged on 1/12/17. A discharge summary was not documented in the client's record.
These findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
In reference to missing client records, these specific counselors were individually re-trained and also have had paperwork added to their supervision goals and have also been formally addressed as to any continued non-compliance with charting.Need for increased oversight will be primarily addressed through new processes with EMR which will within My Alerts to notify any missing documentation. All staff at this office were re-trained on need for case consultations when there are disruptions in treatment services or gap in service due to extenuating circumstances such as participation in higher LOC. Staff were made aware that simple DAP note indicating current reasons for not being able to participate in treatment and anticipated return would be sufficient to explain lack of attendance in services or the reason for discharge from services. Also included in EMR is a "discharge bundle" which on a taskbar will highlight needed documentation when a client is being discharged. For clients that require follow up contact, staff will rely on prior form which documents follow up call and this form will be uploaded into clients electronic chart. Lastly clinical staff will have a direct role in discharging clients from their active caseload, which in the past has not been the case and this will reinforce the need to appropriately address treatment status. Supervisory oversight will occur during course of chart audits, Clinical Directors will be responsible for ensuring corrective actions are implemented as well as ongoing oversight related to this standard. Supervisory follow up will occur through report that identifies frequency of last service, when staff has client that crosses 30 day mark or last session, supervisor should follow up with staff to get an update and also ensure that proper documentation has occurred to reflect disruption in services. |