INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 24, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
During an onsite annual licensure inspection on April 24, 2019 fire drill logs from the previous 12 months were reviewed. The facility failed to provide documentation of fire drills conducted on different days of the week, at different times of the day and on different staffing shifts.
The facilities operating hours are Monday - Thursday 08:00 am-9:00 pm and Friday 08:00 am-5:00 pm.
There were fire drills conducted on four Fridays and five Mondays and one Wednesday. Of those fire drills recorded seven were logged as occurring during times the facility was not in operation.
Friday-February 15, 2019- 10:00 pm-10:35 pm
Friday- January 11, 2019- 10:00 pm- 10:35 pm
Monday- December 3, 2018- 10:00 pm- 10:35 pm
Monday- November 19, 20118- 11:00 pm-11:35 pm
Friday- October 19, 2018- 10:00 pm- 10:35 pm
Wednesday- August 1, 2018- 10:00 pm- 10:35 pm
Friday- July 20, 2018
Monday- June 11, 2018
Monday- April 2, 2018- 10:00 pm- 10:35 pm
Monday- March 26, 2018
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director and Facility Director met to discuss how monthly fire drills are conducted. We reviewed the process and determined changes should be made to stagger times of drills by date and time so that monthly drill reflect a variety of times, dates and participants. Facility Director has a better understanding of this requirement and will comply with future monthly drills. Program Director will monitor for ongoing compliance. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records on April 24, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 1.
Client # 1 was admitted on May 7, 2018 and was still and active client at the time of the inspection. A release of information was signed and dated on August 13, 2018 to an insurance/government agency allowed for the release of medical records.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A team meeting was held on 4/22/19 in which Program Director reviewed with staff the procedure for completing release of information consents. Staff was made aware that information must be limited to the specific 5-points on the release form. Quality Assurance Manager will ensure compliance through regular chart reviews and will keep Program Director informed in order to monitor ongoing compliance. |
715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
During a licensing inspection conducted on April 24, 2019, the facility failed to provide documentation of a policy and procedure that was developed regarding involuntary terminations.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
MAT policy and procedure was amended to include specific information related to involuntary terminations. Psychiatrist and treatment team had been aware of the grounds for involuntary termination as this information has been included on the Informed Consent/Patient Agreement for MAT. Program Director updated P&P manual with this information.
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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
During a licensing inspection conducted April 24, 2019, the facility failed to provide documentation in five of seven client records reviewed that the criteria for admission, treatment, completion and discharge was disclosed to the client during the intake procedures.
Client # 2 was admitted on January 24, 2019 and was still an active client at the time of the inspection. No documentation was in the record that the facility disclosed to the client the criteria for admission, treatment, completion and discharge at the time of intake.
Client # 3 was admitted on February 28, 2019 and was still an active client at the time of the inspection. No documentation was in the record that the facility disclosed to the client the criteria for admission, treatment, completion and discharge at the time of intake.
Client # 4 was admitted on December 31, 2018 and was still an active client at the time of the inspection. No documentation was in the record that the facility disclosed to the client the criteria for admission, treatment, completion and discharge at the time of intake.
Client # 6 was admitted on December 14, 2018 and was discharged on July 24, 2018. No documentation was in the record that the facility disclosed to the client the criteria for admission, treatment, completion and discharge at the time of intake.
Client # 7 was admitted on February 27, 2019 and was discharged on April 9, 2019. No documentation was in the record that the facility disclosed to the client the criteria for admission, treatment, completion and discharge at the time of intake.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In the past, this information had been conveyed verbally during intake sessions. However, in order to improve documentation of this exchange, a new form was created which explains criteria for admission, discharge, treatment and treatment completion. Staff were trained on the new form and it is used with all individuals at the time of intake so they are apprised of this information. Assistant Director and QA Specialist will perform chart audits to ensure the form is being used and retained. Program Director will monitor for on-going compliance. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
During a client record review conducted on April 24, 2019, the facility failed to provide documentation of client orientation to the project to include project policies, hours of operation, fee schedule, and services provided in five of seven records reviewed.
Client # 2 was admitted on January 24, 2019 and was still an active client at the time of the inspection. No documentation was in the record that the facility provided a client orientation to the project to include project policies, hours of operation, fee schedule, and services provided.
Client # 3 was admitted on February 28, 2019 and was still an active client at the time of the inspection. No documentation was in the record that the facility provided a client orientation to the project to include project policies, hours of operation, fee schedule, and services provided.
Client # 4 was admitted on December 31, 2018 and was still an active client at the time of the inspection. No documentation was in the record that the facility provided a client orientation to the project to include project policies, hours of operation, fee schedule, and services provided.
Client # 6 was admitted on December 14, 2018 and was discharged on July 24, 2018. No documentation was in the record that the facility provided a client orientation to the project to include project policies, hours of operation, fee schedule, and services provided.
Client # 7 was admitted on February 27, 2019 and was discharged on April 9, 2019. No documentation was in the record that the facility provided a client orientation to the project to include project policies, hours of operation, fee schedule, and services provided.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director updated Orientation Package to include information specific to policies, hours of operation and fees for consistent use across the program. It was reviewed with Clinical Supervisor and Facility Director and all clients receiving services shall receive this orientation guide. Clients shall sign-off to include receipt of the information and the guide will be retained in the client file. QA Specialist and Program Director will monitor for ongoing compliance. |
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
During a client record review conducted on April 24, 2019, the facility failed to document complete client records to include referral contact, case consultation, and follow-up.
Client # 1 was admitted on May 7, 2018 and was still an active client at the time of the inspection. There was no documentation of a referral contact in the client record.
Client # 2 was admitted on January 24, 2019 and was still an active client at the time of the inspection. There was no documentation of a referral contact in the client record.
Client # 3 was admitted on February 28, 2019 and was still an active client at the time of the inspection. There was no documentation of a referral contact in the client record.
Client # 4 was admitted on December 31, 2018 and was still an active client at the time of the inspection. There was no documentation of a referral contact in the client record.
Client # 5 was admitted on December 5, 2016 and was discharged on December 3, 2018. There was no documentation of follow-up information or case consultation notes in the client record.
Client # 6 was admitted on February 14, 2018 and was discharged on July 24, 2018. There was no documentation of a referral contact or case consultation notes in the client record.
Client # 7 was admitted on February 27, 2018 and was discharged on April 9, 2019. There was no documentation of a referral contact in the client record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director conveyed meeting on 4/25/19 with Intake Specialist, Assistant Director, Clinical Supervisor/QA Specialist and Administrative Assistant to discuss the need to load the referral contact into the client record. Mazzoni Center's practice has been consistent in obtaining this information, we need to ensure it is kept in the client files, along with case consultation notes and follow-ups. Staff now have a better understanding of this requirement and will organize this material in the client files. Program Director and managers will monitor for ongoing compliance. |