INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20-21, 2013 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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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the project's policy and procedure manual, the facility failed to document an annual evaluation of the overall training plan within the timeframe outlined in the manual.
The findings include:
Facility policy states that the overall evaluation of the training plan will be completed by Administration in December of each year. The facility did not document the completion of the overall evaluation of the training plan until April 30, 2013.
The Project Director confirmed the findings.
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Plan of Correction
The Agency Director is responsible for this area of compliance. He/She will provide a written report evaluating the years training activity by 12/31 of each year. This report will be presented to the Board by January 31 of each subsequent year. Minutes of this meeting will insure sompliance |
705.27 (5) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(5) Notify the Department within 48 hours of a fire, other disaster or situation which affects the continuation of services.
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Observations
Based on a review of the policy and procedure manual, the facility failed to notify the Department within 48 hours of a disastrous situation which affects the continuation of services.
The findings include;
A review of the policy and procedure manual as well as a discussion with the Project Director was completed on May 20, 2013. The facility confirmed that Hurricane Sandy affected the continuation of their services on October 29, 2012. The facility failed to notify the Department of this interruption in service.
The Project Director confirmed the findings.
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Plan of Correction
The agency director is responsible for compliance to this reg. The agency director is now clearly aware of the regulation to inform DDAP in we are interrupting services for an emergency. The agency director has also informed all personnel regarding this requirement. Information in the operations manual now includes DDAP phone # to conact should the need arise. |
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 document on the treatment plan update the client's progress as it relates to the goals identified in the treatment plan in four of seven records reviewed.
The findings were:
Seven client records requiring treatment plan updates which include progress on stated goals were reviewed on May 21, 2013. The facility failed to document on the treatment plan update the client's progress as it relates to the goals identified in the treatment plan in four of seven records reviewed, specifically records # 1, 2, 5, and 7.
Client # 1 was admitted into treatment on 9/6/12 and was still an active client at the time of the inspection. The facility failed to document progress on the treatment plan updates completed on 10/22/12, 1/31/13, 2/27/13, and 4/22/13 as it related to goals identified on the treatment plan.
Client # 2 was admitted into treatment on 12/10/12 and was still an active client at the time of inspection. The facility failed to document progress on the treatment plan updates completed on 2/10/13 and 4/10/13 as it related to goals identified on the treatment plan.
Client # 5 was admitted into treatment on 11/5/12 and was still an active client at the time of the inspection. The facility failed to document progress on the treatment plan updates completed on 1/8/13 and 3/12/13 as it related to goals identified on the treatment plan.
Client # 7 was admitted into treatment on 1/10/13 and was still an active client at the time of the inspection. The facility failed to document progress on the treatment plan update completed on 3/18/13 as it related to goals identified on the treatment plan.
The Project Director confirmed the findings.
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Plan of Correction
The agency director is responsible of compliance to this reg. The agency director will train staff to document clients progress on treatment plan updates. If client1,2,5,and 7 are still active, therapists of record will add an addendum to the treatment plan to more specifically detailing clients progress. Random chart reviews by supervising staff will 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 assure counseling services were provided according to the individual treatment and rehabilitation plan in four of eleven client records reviewed.
The findings include:
Eleven client records requiring documentation that services were being provided in accordance with the treatment plan were reviewed on May 21, 2013. The facility failed to provide documentation that services were being provided in accordance with the treatment plan in four of eleven records, specifically client records # 5, 7, and 11.
Client # 5 was admitted into treatment on 11/5/12 and was still an active client at the time of the inspection. According to the treatment plan, this client was to be getting one individual session per week. The facility failed to document any individual sessions for the weeks of 12/16/12, 12/23/12, 12/30/12, 1/20/13, 1/27/13, 3/17/13, and 3/31/13. Additionally, as of 5/21/2013, the last documented session in the record was 4/15/13.
Client # 7 was admitted into treatment on 1/10/13 and was still an active client at the time of inspection. According to the treatment plan, this client was to be getting one individual session per week and three group sessions per week. The facility failed to document individual sessions on the following weeks: 1/15/13, 1/24/13, 2/7/13, 2/14/13, 2/28/13, 3/21/13, 4/7/13, 4/14/13, 4/21/13, 4/28/13, 5/10/13, and 5/14/13. The facility documented only two group sessions the weeks of 2/3/13, 3/3/13, 3/10/13, 3/24/13, 3/31/13, 4/7/13, 4/14/13, 4/21/13, and 4/28/13 and documented only one group session the weeks of 1/27/13, 5/5/13, and 5/12/13.
Client # 11 was admitted into treatment on 12/12/12 and discharged on 1/28/13. According to the treatment plan, this client was to be getting two individual sessions per week and one group session per week. The facility failed to document any individual sessions the weeks of 1/6/13, 1/13/13, and 1/20/13 and documented only one group session the week of 1/3/13.
The Project Director confirmed the findings.
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Plan of Correction
The agency director is responsible for compliance of this reg. Trianing by the agency director will address the type and frequency of services to accurately reflect what the client is recieving. An addendum will be added to client 5, 7, 11 to indicate why individual sessions were not attended. Rendom review of records by supervisory staff will insure compliance |