INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 5, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 31, 2007.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
The facility failed to present the plan documenting the qualifications and training of staff at the time of the site visit.
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Plan of Correction
The Project Director failed to complete staff qualifications and training documentation prior to the Licensing Specialist's site visit. The Project Director completed documentation during the site visit and provided completed documentation to the Licensing Specialist during her visit. In the future, the Project Director will carefully read instruction regarding preparation for site visits and make sure that all required paperwork is completed prior to Licensing Specialist's visit. |
705.1 (2) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
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Observations
The facility failed to provide a Certificate of Occupancy from the Department of Labor and Industry or its local equivalent.
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Plan of Correction
The Certificate of Occupancy for Mission New Life's First Church Clinic was misfiled and not available when the Licensing Specialist visited the facility. The Project Director found the Certificate of Occupancy after the visit and provided a copy to the Department of Health on July 13, 2007. The Project Director will review Mission New Life filing systems to ensure that all documentation is properly filed and readily retrievable. In the future, the Project Director will make sure that all documentation is avialable for the Licensing Specialist prior to his/her visit. |
705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
The facility failed to provide written procedures for staff and clients to follow in case of an emergency. The facility's policy did not address internal versus external disasters or evacuation to a safe location.
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Plan of Correction
Transition to Community (TTC) hosts Mission New Life in a building owned by the Water Street Rescue Mission (WSRM). Mission New Life trains its staff in use of fire extinguishers and conducts its own fire drills, using evacuation routes and evacuation procedures developed by Mission New Life. Mission New Life's Project Director will determine TTC's, WSRM's, and the City's disaster plans, assess how they relate to Mission New Life's operations, and develop a specific Disaster Plan for Mission New Life, which addresses both internal and external disasters. The Project Director will train Staff regarding emergency procedures including chain of command, responsibility, and accountability. The Project Director will incorporate the associated policy, procedures, and plans into Mission New Life's Policy & Procedures Manual. |
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
The facility failed to conduct unannounced fire drills at least once a month. Specifically, a fire drill was not documented for March 2007.
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Plan of Correction
Failing to perform a fire drill in March 2007 was an oversight. The Project Director and Facility Director will discuss how to ensure that fire drills are executed at least monthly. Specifically, the Project Director will program his computer to randomly call for unannounced fire drills. When the Project Director's computer signals a fire drill, the Project Director will call the Facility Director and order a fire drill. In the event, the Facility Director is unavailable, the Project Director will ask for the person in charge and order a fire drill. The Facility Director, or the person he leaves in charge, will be accountable for conducting the fire drill. The Facility Director will be accountable for at least one unannounced fire drill each month. The Project Director will be responsible for oversight. |
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
The facility failed to conduct fire drills on different days of the week and at different times of the day.
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Plan of Correction
The Project Director holds the Facility Director accountable for conducting monthly fire drills. The Project Director failed to advise the Facility Director that he would be accountable for conducting fire drills at different days of the week and at different times of the day. In the future, the Facility Director will see to it that the fire drills occur on different days of the week and at different times of the day. The Project Director will provide oversight. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
The facility failed present an annual report.
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Plan of Correction
Activities and accomplishments and a financial statement as well as names of officers of Mission New Life were available for Year 2006. However, health issues and workload prevented the Project Director from compiling this data into an annual report for Year 2006. The Project Director will compile available data into a Year 2006 Annual Report. Specifically, the Project Director will reformat existing data into an annual report, publish the report, distribute the report to Mission New Life advisors and other interested parties, and publish a notice in the Lancaster Newspapers that Mission New Life's Year 2006 Annual Report is available to the public for review at Mission New Life's clinic at 39 West Vine Street or that a copy of Mission New Life's Year 2006 Annual Report can be obtained by sending a written request to Mission New Life's administrative office at 203 Crescent Drive in Hershey. Regarding future annual reports, the Project Director will train the Administrative Assistant to compile data required for Mission New Life's annual report on a month-to-month basis. She will be accountable for providing the Project Director with a draft annual report within three months of the end of the report year. The Project Director will be accountable for the actual publication, distribution, and notification of availability of each annual report. If for any reason the Project Dirctor is incapacitated, the Associate Director will be held accountable for the publication, distribution, and notification of avaiability of the relevant annual report. |
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
The facility failed to have a written agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage. The written agreement on file had an expiration date of 2005.
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Plan of Correction
The Project Director failed to renew Mission New Life's agreement with Lancaster General Hospital for 24-hour psychiatric and medical coverage. The Project Director will seek an updated agreement with Lancaster General Hospital for 24-hour psychiatric and medical coverage. To ensure that written agreements for 24-hour psychiatric snd medical coverage are maintained in the future, Mission New Life will develop a tickle system to warn of approaching expiration dates. Mission New Life will hold the Administrative Assistant accountable for monitoring the tickle system, preparing a new agreement two months prior to expiration, and submitting to the Project Director for execution and forwarding to Lancaster General Hospital for execution on their part and return to Mission New Life our records. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
The facility failed to follow their written policy to have all clients receive a physical examination. Physical examinations were missing in three of four client records reviewed, #2, 3 and 5.
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Plan of Correction
Mission New Life's Policy & Procedure regarding physical examinations requires clarification. Mission New Life's policy does not require all clients to obtain a physical examination. The Project Director will revise Mission New Life's Policy & Procedure regarding Physical Examinations, review with Staff, and incorporate a revised policy statement into Mission New Life's Policy & Procedures Manual. |
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
The facility failed to document a complete psychosocial evaluation in four of four client records reviewed, #1, 2, 3 and 5. The client's presenting and underlying problems were not clearly addressed in four of four client records reviewed, #1, 2, 3 and 5. Client problems simply noted drug/alcohol use and were not based on individual client needs. Client assets/strengths were missing in two of four client records reviewed, #3 and 5. Coping mechanisms listed were simply drug/alcohol use in four of four client records reviewed, #1, 2, 3 and 5.
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Plan of Correction
Mission New Life's intake and
admission procedure requires presentation and processing of 55 pages of documentation including 30 forms that require client and witness dated signatures. To complete the evaluation and assessment, the counselor must process a 12-page client history questionnaire. The Counselor then summarizes all this with a Pennsylvania Client Placement Criteria summary sheet, a Case Consultation Note, and a Psychosocial Summary. We find this very difficult to do in three hours of face-to-face client contact and within seven days. We find it especially difficult when working with clients who are Court stipulated and speak only Spanish (most of Mission New Life's clients). Hence, we use an abbreviated Psychosocial Summary form (2 pages) in an effort to save time and energy. In the rush to get everything done on time, Mission New Life counselors some-times do not provide sufficient detail in a client's psychosocial summary. The Project Director will meet with Mission New Life clinical staff, review the current Psychosocial Summary form, assess additional data required to document a Psycho-social Summary that meets Department of Health Standards, revise the current form, and incorporate it into Mission New Life's Policy & Procedures Manual. The Clinical Director will follow up with Clinical Staff to ensure successful implementation of revised procedures. The Project Director will provide oversight.
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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
The facility failed to formulate individualized, realistic goals stated in terms of measurable criteria in two of four client records reviewed, #3 and 5.
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Plan of Correction
Mission New Life's Clinical Staff routinely takes BDAP sponsored training on Treatment Planning including formulation of individual-ized, realistic treatment goals and objectives. Nevertheless, we still find formulation of concrete and measurable client treatment goals and objectives (with client partici-pation) very elusive. We know we must be more effective to meet Department of Health Standards. We plan to focus on treatment planning in upcoming case con-ferences until the staff is comfort-ably proficient in formulating indiv-idualized, realistic treatment goals and objectives. The Clinical Director will monitor and review Counselor performance in monthly supervisory sessions. The Project Director will provide oversight. |
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
The facility failed to review and update treatment plans at least every 60 days. Treatment plan updates were missing in two of three client records reviewed, #1 and 5. The treatment plan update was 30 days late in client record #3.
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Plan of Correction
Lack of Administrative Staff requires Mission New Life Counselors to perform much of the administrative work associated with the clients assigned to them. The additional burden on Counselors sometimes interferes with timely completion of required treatment management activities such as reviewing and updating individual treatment and rehabilitation plans. The Project Director will work with Mission New Life Clinical Staff to review current policy & procedures for managing treatment, develop a schedule for performing required treatment activities, a timeline for doing so, update Mission New Life's Policy & Procedures regarding Treatment Management, and incorporate into the Policy & Procedures Manual. The Administrative Assistant will monitor Client Charts for upcoming treatment events, alert Counselors, and monitor timely completion of associated activities. The Clinical Director will monitor implementation through monthly supervisory sessions with individual Counselors. The Project Director will provide oversight. |
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
The facility failed to document an individualized aftercare plan in one of one client record reviewed, #5. The goals listed were not individualized and did not include time frames.
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Plan of Correction
Mission New Life needs to be more explicit in what is required to manage treatment according to Department of Health Standards and be more specific in when treatment activities must occur. We must then train and supervise staff to ensure that Mission New Life Counselors meet Department of Health treatment management standards. We plan to focus on treatment planning including aftercare treatment planning in upcoming case conferences until the staff is comfortably proficient in formulating individualized, realistic treatment goals and objectives. The Clinical Director will monitor and review Counselor performance in monthly supervisory sessions. The Project Director will provide oversight |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
The facility failed to document a discharge summary in one of two client records reviewed, #4.
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Plan of Correction
Mission New Life Policy is to prepare a Discharge Summary for each client admitted to Mission New Life and subsequently discharged. Lack of a Discharge Summary was an oversight. To help Mission New Life Counselors avoid such omissions in the future, the Administrative Assistant will monitor clients charts on a weekly basis and bring deficiencies to the Clinical Director's attention. The Clinical Director will advise individual Counselors of specific deficiencies immediately and review overall performance in monthly supervisory sessions. The Project Director will provide oversight. |
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
The facility failed to document follow-up information in two of two client records reviewed, #4 and 5.
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Plan of Correction
Mission New Life' current policy is to follow up with clients at 30 , 90, 180, and 365 says after discharge. Mission New Life has not been able to adhere to this policy. The Project Director will review the current Policy & Procedure with staff, develop a more realistic Policy & Procedure, and incorporate into Mission New Life's Policy & Procedures Manual. The Clinical Director will monitor future cases to ensure follow-up of discharged clients. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
The facility failed to adhere to the licensed authorized capacity for the Outpatient Drug-Free activity. The authorized capacity is 35. The client census during the licensing inspection was 47.
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Plan of Correction
The Department of Health authorized Mission New Life ? West Vine a maximum capacity of 35 active cases as of November 12, 2004. As of February 2, 2007, Mission New Life ? West Vine had 33 active clients. As of July 4, 2007, the actual number of active cases at Mission New Life ? West Vine increased to 42. The Project Director should have requested an increase in authorized capacity prior to May 31, 2007. He did not do so. As of July 28, 2007, the Project Director submitted a request to increase authorized capacity to 85. To ensure that Mission New Life does not exceed authorized capacity in the future, Mission New Life will hold the Facility Director accountable for monitoring client census on a day-by-day basis. When the Mission New Life - West Vine census comes within five clients of capacity, the Facility Director shall alert the Project Director and a joint decision will be made whether to look for potentional discharges, begin to make strategic referrals, or to request an increase in authorized capacity. |