INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 15-16, 2011 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on April 19, 2011.
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Plan of Correction
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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
Based on the review of personnel records and an interview with the project director, the facility failed to document a minimum of 6 hours of HIV/AIDS training in one of four personnel records.
The findings include:
On March 16, 2011, five personnel records were reviewed for documentation of 6 hours of HIV/AIDS training. The facility did not document 6 hours of HIV/AIDS training in personnel record #2.
Personnel #2 was identified as the clinical supervisor and required documentation of 6 hours of HIV/AIDS training within the first year of employment.
Personnel #2 was hired in February 2008, but 6 hours of HIV/AIDS training was not documented at the time of inspection. A certificate for HIV training was included in personnel record #2, but the training certificate did not state the number of training hours.
An interview with the project director on March 16, 2011, confirmed that personnel record #2 did not contain documentation of 6 hours of HIV/AIDS training.
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Plan of Correction
Staff #2 has been registered for State-Mandated HIV training on 4/14/11. Upon completion, certificate of training will be submitted to HR to be added to staff personnel record. Program Director will monitor for compliance.
In the future, all program personnel will complete 6 hours of HIV training within one year of hire. Program Director will ensure compliance during review of yearly training plan. HR will maintain records in staff personnel file. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on the review of personnel records and an interview with the project director, the facility failed to document at least 25 clock hours of training annually in one of two personnel records.
The findings include:
On March 16, 2011 two personnel records identified as counselors during the 2010 training year were reviewed for documentation of 25 clock hours of training. The facility did not document 25 hours of training during the 2010 training year in personnel record #5.
Personnel record #5 documented only 12 hours of training for the 2010 training year.
An interview with the facility director on March 16, 2011, confirmed that personnel record #5 did not contain at least 25 hours of training for the 2010 training year.
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Plan of Correction
Staff #5 was counseled on the training requirements per state and agency policy. The definition of "training year" was clarified and staff now understands the requirement more thoroughly. Program Director and staff #5 reviewed 2011 staff Professional Development Plan to ensure staff will meet training requirements for the present training year.
In the future, Program Director will review staff training logs on a quarterly basis to ensure all program staff, especially staff #5 in completing training requirements spelled out on annual professional development plan. HR manager will assit in coordination of review. |
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
Based on the review of client records and an interview with the project director, the facility failed to document a psychosocial evaluation that included conclusions regarding the client's appearance, behavior and reactions during the initial interview and conclusions regarding the client's attitude toward and ability to participate in the treatment process in accordance with the facility's policy and procedures.
The findings include:
On March 16, 2011 six client records were reviewed for documentation of a psychosocial evaluation. The facility did not document a psychosocial evaluation to include a composite picture of the individual in relation to the collected historical information, as per facility policy, in client records # 1, 2, 4, 5, 6 and 7.
The facility's policy titled " Comprehensive Biopsychosocial History and Evaluation (to be completed on or before 4th session) " states:
" Purpose: To provide a composite picture of the individual in relation to the collected historical information, ensuring that the necessary information for making adequate treatment decisions is obtained consistently for all clients. This will assist in determining the appropriate level of care for each client. The content of such evaluation should include, and not be limited to, a clear description of the client (with presenting and underlying problems); client needs/barriers that might inhibit treatment; client strengths or positive attributes that might contribute to the resolution of problems; potential support systems; negative factors that might affect treatment; client's preferred coping mechanisms; conclusions regarding the client's appearance, behavior and reactions during the initial interview, conclusions regarding the client's attitude toward and ability to participate in the treatment process, treatment recommendations, and preliminary treatment and discharge planning. "
The psychosocial evaluation in client record #1, dated 12/22/10 did not include (1) conclusions regarding the client's appearance, behavior and reactions during the initial interview and (2) conclusions regarding the client ' s attitude toward and ability to participate in the treatment process.
The psychosocial evaluation in client record #2, dated 9/1/10 did not include (1) conclusions regarding the client's appearance, behavior and reactions during the initial interview and (2) conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The psychosocial evaluation in client record #4, dated 12/17/10 did not include (1) conclusions regarding the client's appearance, behavior and reactions during the initial interview and (2) conclusions regarding the client ' s attitude toward and ability to participate in the treatment process.
The psychosocial evaluation in client record #5, dated 7/6/10 did not include (1) conclusions regarding the client's appearance, behavior and reactions during the initial interview and (2) conclusions regarding the client ' s attitude toward and ability to participate in the treatment process.
The psychosocial evaluation in client record #6, dated 12/8/11 did not include (1) conclusions regarding the client's appearance, behavior and reactions during the initial interview and (2) conclusions regarding the client ' s attitude toward and ability to participate in the treatment process.
The psychosocial evaluation in client record #7, dated 2/2/10 did not include (1) conclusions regarding the client's appearance, behavior and reactions during the initial interview and (2) conclusions regarding the client's attitude toward and ability to participate in the treatment process.
An interview with the project director on March 16, 2011 confirmed that the identified client records did not contain a psychosocial evaluation documented in accordance with facility policy.
This is a repeat citation. The facility was cited on April 15, 2010 and September 28, 2010 for failing to document psychosocial evaluations.
In response to the citation issued on September 28, 2010, the facility provided the following plan of correction:
" Program Director held meeting with staff to address this deficiency on 10/18/2010. Staff was instructed on how to properly incorporate client's assets/strengths, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment into the case conceptualization/conclusion part of the client evaluation.
Having been trained and now having a better understanding of what is expected, staff will begin immediately incorporating these changes into their documentation.
Clinical supervisor and Program Director will monitor on an on-going basis to ensure compliance. "
The facility indicated they would be in compliance with this standard by 10/20/10.
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Plan of Correction
Program Director and Clinical Supervisor will review psychosocial evaluation in client records # 1,2,4,5,6,7. Staff responsible for corresponding client charts will be responsible for amending information on the psychosocial evaluation by 4/15/11 to reflect (1) conclusions regarding the client's appearance, behavior and reactions during the initial interview and (2) conclusions regarding the client's attitude toward and ability to participate in the treatment process. Clinical Supervisor and Progrma Director will review to ensure compliance.
To improve documention in this area in the future, Program Director edited psychosocial evaluation form on 3/31/11 to elicit more precise feedback and conclusions from therapists regarding client's appearance, behavior and reactions, as well as client's attitude toward and ability to participate in treatment.
Program Director will hold in-service team meeting with staff on 4/11/11 to review revised forms and instruct staff on its use.
Clinical Supervisor will review charts on a monthly basis to ensure compliance. Program Director will perform random quarterly reviews to ensure standard is met in this area and provide additional training and counseling as necesary.
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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
Based on the review of client records and in interview with the project director, the facility failed to document a treatment plan in accordance with facility policies and procedures three of five records.
The findings include:
On March 16, 2011 five client records were reviewed for documentation of treatment plans. The facility did not document a treatment plan, as per facility policy, in client records # 2, 5 and 7.
The facility's policy titled " Initial Treatment Plan (to be completed before the 5th session) " states:
" Purpose: This tool is used, more specifically, to document short-term goals, long-term goals, and action steps to attain all goals. The counselor and the client should complete this together, and should include supportive/adjunct services, progress, strengths/barriers, duration and methodology of treatment and D/C planning. "
Client record #2 contained progress notes documenting counseling sessions on 7/2/10, 8/18/10, 8/25/10, 9/1/10, 9/7/10, 9/14/10, 9/21/10, 9/28/10, 10/5/10 and 10/12/10, but the Initial Treatment Plan was dated 10/12/10.
Client record #5 contained progress notes documenting counseling sessions on 7/6/10, 7/12/10, 7/22/10, 7/29/10, 8/6/10 and 8/12/10, but the Initial Treatment Plan was dated 8/12/10.
Client record #7 contained progress notes documenting counseling sessions on 1/4/11, 1/19/11, 1/26/11, 2/2/11, 2/9/11, 2/16/11 and 3/2/11, but the Initial Treatment Plan was dated 3/2/11.
This is a repeat citation. The facility was cited on April 15, 2010 for failing to document treatment plans.
In response to the citation issued on April 15, 2010, the facility provided the following plan of correction:
" Program Director amended agency's policy and procedure manual to reflect due date for the comprehensive treatment plan to occur by the fifth session in order to better develop a comprehensive plan of treatment taking into account missed sessions after intake.
Staff was informed of this change during a team meeting on 4/19/2010.
Clinical Supervisor and Program Director will oversee on-going compliance. Program Director will revisit with staff during in-service meetings on a quarterly basis. "
The facility indicated they would be in compliance with this standard by 5/7/10.
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Plan of Correction
Program Director recognizes this has been an ongoing challenge for program staff and, therefore, PD is implementing a new strategy to assist staff with preparation and organization of Initial Treatment Plans.
Program Director will develop an electronic spreadsheet for each staff to use which will reflect the due dates of all client matierial, including Initial Treatment Plans. Effective 4/18/11, staff will utilize this spreadsheet as a visual reminder of ITP due dates.
Staff will be expected to review spreadsheets on a monthly basis with Clinical Supervisor to ensure it is being implemented and also to ensure ITP are being completed on a timely basis. Program Director will hold random chart reviews on a quarterly basis to ensure compliance on an ongoing basis.
Program Director will introduce this new strategy during a team meeting on 4/11/11.
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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 the review of client records and in interview with the project director, the facility failed to document a treatment plan update in accordance with facility policies and procedures in three of three client records.
The findings include:
On March 16, 2011 three client records were reviewed for documentation of treatment plan updates. The facility did not document a treatment plan update, as per facility policy, in client records # 2, 3 and 5.
The facility's policy titled " Comprehensive Treatment Plan Update (to be completed 60 days after the Initial Treatment Plan, and every 60 days thereafter) " states:
" The plan shall be monitored and re-evaluated by the treatment team for the clients every 60 days during the course of treatment (unless there are circumstances preventing its completion such as a lapse in treatment or sporadic attendance). This update should include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan. "
In client record #2, the initial treatment plan was dated 10/12/10, but the treatment plan update was dated 12/21/10, and another treatment plan update had not been documented 60 days later.
In client record #3, the initial treatment plan was dated 6/23/10, and the first treatment plan update was dated 8/19/10, but the second treatment plan update was date 11/15/10, and the third treatment plan update was date 2/28/11.
In client record #5, the initial treatment plan was dated 8/19/10, but the treatment plan update was dated 12/21/10. The client was then discharged on 2/22/11.
An interview with the project director on March 16, 2011 confirmed that the treatment plans in the identified client records had not been updated every 60 days.
This is a repeat citation. The facility was cited on April 15, 2010 for failing to document treatment plan updates.
In response to the citation issued on April 15, 2010, the facility provided the following plan of correction:
" Prior policy had Treatment Plan updates occurring 60 days from the date of intake and used the date of intake as the marker for all subsequent updates. Policy and procedures were corrected to indicate due date for Treatment Plan updates is 60 days following Comprehensive Treatment Plan completion.
Program Director will review change with staff at in-service meeting on 6/14/10. Director and staff will review due date and procedures for completing plans within specified time-frame.
Clinical Supervisor and Program Director will oversee changes are implemented and Program Director will ensure on-going compliance. "
The facility indicated they would be in compliance with this standard by 5/7/10.
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Plan of Correction
In line with the plan of correction for timely submission of Initial Treatment Plans, PD is implementing a new strategy to assist staff with preparation and organization of Comprehensive Treatment Plans.
Program Director will develop an electronic spreadsheet for each staff to use which will reflect the due dates of all client matierial, including Comprehensive Treatment Plans to be completed 60 days after the Initial Treatment Plan, and every 60 days thereafter.
Effective 4/18/11, staff will utilize this spreadsheet as a visual reminder of CTP due dates.
Staff will be expected to review spreadsheets on a monthly basis with Clinical Supervisor to ensure it is being implemented and also to ensure CTP are being completed on a timely basis. Program Director will hold random chart reviews on a quarterly basis to ensure compliance on an ongoing basis.
Program Director will introduce this new strategy during a team meeting on 4/11/11.
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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 the review of client records and an interview with the project director, the facility failed to document a case consultation in accordance with facility policies and procedures in three of six client records.
The findings include:
On March 16, 2011 six client records were reviewed on for documentation of case consultations. The facility did not document a case consultation at least every three months, as per facility policy, in client records # 2, 4 and 6.
The facility ' s policy titled " Case Consultations " states:
" Case consultation shall be completed at least every three months or more frequently if needed, and at least once annually if the client remains in treatment over one year. "
Client #2 was admitted to the program on 7/21/10, but the first case consultation was not documented until 11/4/10, and another has not been documented since.
Client #4 was admitted to the program on 10/27/10, but a case consultation was not documented at the time of review on 3/16/11.
Client #6 was admitted to the program on 12/8/10, but a case consultation was not documented at the time of review on 3/16/11.
An interview with the project director on March 16, 2011, confirmed that the facility did not document a case consultation in accordance with facility policy in the identified client records.
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Plan of Correction
During the site inspection on 3/16/11, Program Director received clarification of the standard related to case consultation, and now has an accurate understanding of timing.
Program Director and Clinical Supervisor held a meeting on 3/30/11 to review this policy. All future case consultation notes will be timed according to the client's initial intake date, not the date of the first therapy session as was previously occuring and thereby putting us out of compliance.
Program Director will perform random chart reviews on a quarterly basis to ensure compliance on an ongoing basis. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection and an interview with the project director, the facility failed to display the hours of operation conspicuously to the general public.
The findings include:
A physical plant inspection was conducted on March 16, 2011 at approximately 12:30 PM. The facility was required to display the hours of operation to the general public, but at the time of inspection the hours of operation were posted in a counseling office only, and not displayed for the general public.
An interview with the project director on March 16, 2011 confirmed that the hours of operation were not displayed to the general public.
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Plan of Correction
Program Director will post hours of operation in the lobby of the building in view for the general public by 4/7/11 where they will remain posted on an ongoing basis. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection and an interview with the project director, the facility failed to display a telephone number conspicuously to the general public.
The findings include:
A physical plant inspection was conducted on March 16, 2011 at approximately 12:30 PM. The facility was required to display telephone number to the general public, but at the time of inspection a telephone number was posted in a counseling office only, and not displayed for the general public.
An interview with the project director on March 16, 2011 confirmed that a telephone number was not displayed to the general public.
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Plan of Correction
Program Director will post telephone contact information in the lobby of the building in view for the general public by 4/7/11 where they will remain posted on an ongoing basis. |