INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 9, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mission New Life, 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records and discussion with the acting project/facility director it was confirmed that the facility failed to demonstrate that performance evaluations were conducted semi-annually for the counselor assistant.
The findings were:
Employee record # 3 failed to include a performance evaluation in the personnel record for December 2010. The last record documented performance evaluation was for April 1, 2010. A discussions with the acting facility/project director on August 10, 2011 confirmed that no semi-annual performance evaluation was conducted for Employee #3 since April 1, 2010.
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Plan of Correction
A performance evaluation shall be conducted on a semi-annual basis for all counselor assistants associated with Mission New Life. The clinical director shall be responsible for evaluating the counselor assistant and documenting the semi-annual evaluation. The facility director shall continue to monitor this area to ensure continued compliance of this standard. The pending evaluation shall be completed by the clinical director by October 30, 2011. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records and an interview with the acting project/facility director, the facility failed to document that a staff member, who is a counselor assistant, was working toward meeting the qualifications for the position of counselor.
The findings include:
Five personnel records were reviewed on August 10, 2011. One personnel record pertained to the position of counselor assistant. Per regulation, a counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year. The facility failed to provide documentation that the counselor assistant is working toward meeting the qualifications for the position of counselor in staff record # 3.
Employee # 3 was hired on June 14, 2007. Employee # 3 did not provide documentation by December 31, 2010 that he is working toward counselor status.
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Plan of Correction
Effective immediately the facility shall ensure that all counselor assistants provide verification/proof that they are working toward meeting the qualifications of counselor as required by DOH standards. Specifically, the current counselor assistant shall provide verification of college enrollment, a copy of his most recent transcript, and submit a written letter outlining how he plans to meet the requirements of counselor within the 5 years. The clinical director will be responsible for gathering the necessary documents and submitting them to the personnel department for filing no later than September 30, 2011. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on an observation during a routine inspection, the facility failed to have two exits on every floor with a minimum distance of 15 feet.
The findings include;
The third floor of the facility was viewed during the August 9,2011 on-site inspection. The facility failed to have two exits that are separated by a minimum distance of 15 feet.
A review of past inspection citations and an interview with the acting project director on August 10, 2011 at 12:00 p.m., confirmed the facility is aware of the regulation of two exits per floor at a distance of 15 feet or more.
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Plan of Correction
On October 14, 2011, Mission New Life submitted a request for exception from the standards related to the distance between fire exits on the third floor. The Department of Health will make a decision regarding the waiver. Should the waiver not be granted, Mission New Life will vacate the third floor. The Executive Director will keep in contact with the Department of Health regarding the third floor fire exit. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log, the facility failed to document a monthly fire drill.
The findings include:
The fire drill record log was reviewed on August 9, 2011 from August 2010 through August 2011. Staff failed to document that a fire drill was conducted for the month of August 2010. The administration assistant confirmed on August 9, 2011 at approximately 11:00 a.m. that that the August 2010 was not completed.
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Plan of Correction
Effective immediately the office manager shall be responsible for conducting monthly fire drills and ensuring that one fire drill per month is conducted according to standard. The facility director will randomly audit the fire drill log to ensure continued compliance in this area. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
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Observations
Based on a review of administrative documentation, the facility failed to maintain written letters of agreement with primary referral sources.
The findings include:
A review of the project's written letters of agreements on August 9, 2011, revealed that all the facility's letters of agreements were outdated.
There were no current letters of agreements available.
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Plan of Correction
On August 19, 2011 Mission New Life mailed written letters of agreement to all referral sources. The office manager shall be responsible to ensure that all letters of agreement remain current at all times. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
709.24(c) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(c) The project shall maintain a current community resource listing of other health and social service agencies.
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Observations
Based on a review of administrative documentation, the facility failed to maintain a current community resource listing of other health and social service agencies.
The findings include:
During the on-site inspection on August 9, 2011, the facility failed to maintain a current community resource listing. The acting Project Director confirmed all resources were out-dated and the facility failed to maintain a current community resource list.
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Plan of Correction
Effective immediately, all staff have internet access where they can print community resource information at any time. Also effective immediately, Mission New Life has made a current community resource listing available to all staff and clients. The office manager shall ensure that a copy of the community resource listing is attached to the policy and procedure's manual. The office manager shall also ensure that a copy of the community resource listing remains available in at least one office on each floor by August 31, 2011. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
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
Based on a review of letters of agreement and an interview with the project director, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
The letters of agreement were reviewed on August 10, 2011. The only letter of agreement regarding 24 hour emergency medical coverage was signed with a local hospital on January 9, 2009. The agreement stipulated that it was in effect for two years and therefore expired on January 9, 2011. There was no other documentation of a 24 hour emergency medical coverage agreement.
The project director was interviewed on August 10, 2011 and confirmed there was no agreement for 24-hour emergency medical coverage.
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Plan of Correction
On July 27, 2011 Mission New Life drafted and mailed a written agreement with Lancaster General Hospital for 24-hour emergency psychiatric and medical coverage. The office manager shall be responsible to ensure that all letters of agreement remain current at all times. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
709.26(a)(10) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(10) Work performance evaluations.
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Observations
Based on a review of personnel records and an interview with the project director, the facility failed to document annual performance evaluations as required by agency policy and regulation in three of three personnel records.
The findings include:
Three personnel records were reviewed on August 9, 2011 All three personnel records were required to include documentation of annual performance evaluations. Per agency policy, performance evaluations are conducted at three months, six months and annually after thereafter. There were no annual performance evaluations that included feedback and confirmation that work performance was evaluated by staff in personnel records #2, 3, and 4.
An interview with the acting project director on August 9, 2011 confirmed the findings.
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Plan of Correction
A performance evaluation shall be conducted on an annual basis for all staff associated with Mission New Life. The facility director shall be responsible for evaluating the clinical directors, the office manager, and the billing agent, the clinical director shall be responsible for evaluating the clinical staff, and the office manager shall be responsible for evaluating all support staff. Initial evaluations shall be completed for all staff by October 31, 2011 and annually (date of hire anniversary date) thereafter. The Facility Director shall continue to monitor this area to ensure continued compliance of this standard. |
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 a review of client records and an interview with the project director, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors in two of five client records.
The findings include:
Five client records were reviewed on August 10, 2011. A psychosocial evaluation was required in five of five records.
Client records #, 2, and 5 failed to include a Psychosocial Evaluation.
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Plan of Correction
Training shall be provided to all clinical staff pertaining to proper case management of client charts during weekly clinical staff meetings beginning August 31, 2011 and continuing throughout the year. The clinical director and/or facility director shall conduct these trainings. When necessary, outside resources shall be used for training purposes. Focus of such training shall be placed on the proper completion of a psychosocial evaluation at the time of intake. The intake counselor shall be responsible for completing the psychosocial evaluation within 48 hours of the initial intake. The clinical director shall conduct bi-weekly chart audits to ensure documentation remain within the specified time frame. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
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
Treatment plans were not individualized in 2 of 5 client records reviewed.
The findings include:
Five client records were reviewed on August 10, 2011. Records # 2 and 3 failed to include a comprehensive treatment plan.
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Plan of Correction
Training shall be provided to all clinical staff pertaining to proper case management of client charts during weekly clinical staff meetings beginning August 31, 2011 and continuing throughout the year. The clinical director and/or facility director shall conduct these trainings. When necessary, outside resources shall be used for training purposes. Focus of such training shall be placed on the proper completion of a comprehensive treatment plan no later than the third individual session with the client. The clinical director shall conduct bi-weekly chart audits to ensure documentation remains within the specified time frame. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of five client records, the facility failed to ensure that the short and long-term goals in the individual treatment plan were individualized for each client.
The findings include:
A review of five client records, specifically #2 and 3, on August 10, 2011 indicated that the therapist failed to individualize the short and long-term goals on the individual treatment and rehabilitation plan. The individual treatment and rehabilitation plan documented in both records failed to include short and long-term goals to address the client's issues or needs.
The comprehensive treatment plan was not included in the client chart. The counselor failed to complete the short and long goals, type and frequency and support services.
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Plan of Correction
Training shall be provided to all clinical staff pertaining to proper case management of client charts during weekly clinical staff meetings beginning August 31, 2011 and continuing throughout the year. The clinical director and/or facility director shall conduct these trainings. When necessary, outside resources shall be used for training purposes. Focus of such training shall be placed on the proper completion of a comprehensive treatment plan which shall include measureable short and long term goals. The clinical director shall conduct bi-weekly chart audits to ensure documentation remains within the specified time frame. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records on August 10, 2011, the facility failed to document type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in two of five records reviewed.
The findings include:
A review of client records # 2 and 3 failed to include type and frequency of treatment and rehabilitation services in the client records.
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Plan of Correction
Training shall be provided to all clinical staff pertaining to proper case management of client charts during weekly clinical staff meetings beginning August 31, 2011 and continuing throughout the year. The clinical director and/or facility director shall conduct these trainings. When necessary, outside resources shall be used for training purposes. Focus of such training shall be placed on the proper completion of a comprehensive treatment plan which shall include type and frequency of services offered/provided to the client. The clinical director shall conduct bi-weekly chart audits to ensure documentation remains within the specified time frame. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records on August 10, 2011, the facility failed to document proposed support services specific to each client in the individual treatment and rehabilitation plan in two of five records.
The findings include:
Five client records were reviewed on August 10, 2011. Record # 2 and 3 failed to include support services in the client records.
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Plan of Correction
Training shall be provided to all clinical staff pertaining to proper case management of client charts during weekly clinical staff meetings beginning August 31, 2011 and continuing throughout the year. The clinical director and/or facility director shall conduct these trainings. When necessary, outside resources shall be used for training purposes. Focus of such training shall be placed on the proper completion of a comprehensive treatment plan which shall include support services offered/provided to the client. The clinical director shall conduct bi-weekly chart audits to ensure documentation remain within the specified time frame. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
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 an on-site inspection on August 10, 2011, the facility failed to review treatment plans and update plans every sixty days.
The findings include:
Five client records were reviewed on August 10, 2011. The facility failed to include treatment plan reviews and updates every sixty days in records #2 and 3. A discussion with the acting project director confirmed the facility director was recently fired and failed to complete the treatment plans in a timely manner.
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Plan of Correction
Training shall be provided to all clinical staff pertaining to proper case management of client charts during weekly clinical staff meetings beginning August 31, 2011 and continuing throughout the year. The clinical director and/or facility director shall conduct these trainings. When necessary, outside resources shall be used for training purposes. Focus of such training shall be placed on the proper completion of comprehensive treatment plan updates at least every sixty days or as client's course of treatment mandates. The clinical director shall conduct bi-weekly chart audits to ensure documentation remain within the specified time frame. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
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 a review of five client records on August 10, 2011, the facility failed to document case consultations in two of three client records.
The findings include:
The facility failed to document case consultation in two of three client records reviewed. Records # 2 and 3 failed to include case consultation notes.
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Plan of Correction
Training shall be provided to all clinical staff pertaining to proper case management of client charts during weekly clinical staff meetings beginning August 31, 2011 and continuing throughout the year. The clinical director and/or facility director shall conduct these trainings. When necessary, outside resources shall be used for training purposes. Focus of such training shall be placed on the proper completion of a case consultation note with the clinical team every sixty days or as the course of treatment mandates. The clinical director shall conduct bi-weekly chart audits to ensure documentation remain within the specified time frame. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and an interview with the acting facility director, the facility failed to document an aftercare plan in two of three client records.
The findings include:
Five client records were reviewed on August 10, 2011. Per facility policy, the counselor and client will complete an aftercare plan at the time of discharge for successful completions. An aftercare plan was required in two of three client records. The facility failed to document an aftercare plan in client record # 3 and 5.
Client record # 3, was admitted on 1/24/2011 and was discharged on 5/26/11. The facility failed to include documentation of an aftercare plan.
Client record # 5 was admitted on 6/04/2010 and discharged on 12/10/10. The facility failed to include documentation on an aftercare plan.
This was discussed and confirmed with the acting facility director on August 10, 2011.
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Plan of Correction
Training shall be provided to all clinical staff pertaining to proper case management of client charts during weekly clinical staff meetings beginning August 31, 2011 and continuing throughout the year. The clinical director and/or facility director shall conduct these trainings. When necessary, outside resources shall be used for training purposes. Focus of such training shall be placed on the proper completion of an aftercare plan within the required time frame. The clinical director shall conduct bi-weekly chart audits to ensure documentation remain within the specified time frame. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
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
Based on a review of client records, the facility failed to document follow-up attempts in three of the five required records.
The findings include:
Five client records were reviewed on August 10, 2011. Three of five client records required follow-up information. Client follow-up was not documented in three of the three required client records.
Record # 1 was admitted on 03/14/2011 and discharged on 07/25/2011.
Record # 3 was admitted on 01/24/2011 and discharged on 05/26/2011.
Record # 5 was admitted on 06/04/2010 and discharged on 01/10/2010.
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Plan of Correction
The facility director, clinical director, and office manager shall revise the follow-up policy and follow-up questionnaire by October 31, 2011. The office manager shall provide training to the office secretary on how to adequately conduct follow-up calls with clients by November 15, 2011. Follow-up will then be conducted on all clients according to Mission New Life's written policies and procedures. The office manager will be responsible for ensuring that follow-up is completed within the specified time frame. The facility director will continue to monitor this standard to ensure continued compliance in this area. |