INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 8/27/2008 and 8/28/2009 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 and a plan of correction is due on September 22, 2009.
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Plan of Correction
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection the facility failed to ensure that the water temperature in the restrooms did not exceed 120 degrees.
The findings include:
Based on the temperature reading of the bathroom sinks during the physical plant inspection on August 27, 2009 the water temperature exceeded 120 degrees. The water temperature in the restrooms was 130 degrees.
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Plan of Correction
Mission New Life's Facility Director has informed the Minister of Administration at First United Methodist Church that the hot water temperature of the restroom facilities used by Mission New Life staff and clients exceeds 120o F by 10o. We have been assured that adjustments have been made to the hot water heater to reduce the water temperature below 120o F. I have asked the Minister of Administration to confirm this is writing. We will retain this written confirmation in our records. |
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
Based on review of the facility's policy and procedure manual, the facility failed to provide a written procedure for staff and clients to follow in case of an emergency.
The findings include:
The policy and procedure manual was reviewed on August 27, 2009; the facility policy and procedure manual did not include a written procedure for evacuation and transfer of staff and clients to follow in the event of an internal and external emergency.
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Plan of Correction
The Mission New Life Project Director will review and update Mission New Life's policy and procedure regarding the evacuation and transfer of clients and staff to a safe location in case of emergency. The Project Director will submit the updated policy and procedure to the Mission New Life Board for its review and approval and then instruct and train the Mission New Life staff on the execution of procedures in the case of an actual emergency. |
705.27 (4) (ii) 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:
(ii) Assignments of staff during emergencies.
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Observations
Based on review of the facility's policy and procedure manual, the facility failed to provide written procedures for staff and clients to follow in case of an emergency.
The findings include:
The policy and procedure manual was reviewed on August 27, 2009. The facility policy and procedure manual did not include a written procedure for staff and clients to follow in case of an emergency which shall include provisions for assignments of staff during emergencies.
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Plan of Correction
The Mission New Life Project Director will review and update Mission New Life's policy and procedure regarding assignments of staff during emergencies. The Project Director will submit the updated policy and procedure to the Mission New Life Board for its review and approval and then instruct and train the Mission New Life staff on the execution of the updated policy and procedures in the case of an actual emergency |
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 the review of the facility fire drill log, they failed to conduct unannounced fire drills at least once a month.
The findings include:
Based on the review of the facility fire drill log on August 27, 2009 the facility failed to document fire drills for the following months: February 2009, April 2009 and June 2009.
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Plan of Correction
At the present time, Mission New Life's First Church Clinic is used sparingly for counseling. Rather it is used primarily as a working office and meeting place. Nevertheless, licensure of the First Street Clinic for drug and alcohol treatment is critical for two reasons. First, Mission New Life's First Church Clinic is its only facility that is fully handicapped accessible. All clients requiring handicapped accessibility are referred to the First Church Clinic. Secondly, Mission New Life plans to expand drug and alcohol treatment services in the near future. The First Church Clinic provides the only available capacity for doing so. To ensure that fire drills are conducted at least once a month, the Facility Director will pre-set in his computer at the beginning of each month, the day of the month and the time of the day at which an alarm will sound signaling a fire drill. Whoever is in the counseling facility (a single Sunday school room in First United Methodist Church) at the time will evacuate the facility. Normal conditions in Mission New Life's First Church Clinic could at various times include the Facility Director/Counselor meeting with a client (or rarely a client and his/her significant other, or a client and his/her family members), the Facility Director/Counselor meeting with a Mission New Life staff member (or staff members), or the Facility Director/Counselor working alone. Mission New Life's First Church Clinic is staffed by the President/Project Director/Facility Director/Counselor. The Associate Director/Counselor backs up the Project Director/Counselor at the First Church Clinic. Both are fully trained to perform assigned tasks during any emergency which could conceivably occur at the First Church Clinic. New staff members will be trained in fire safety policy and procedures within seven days of being assigned to the First Church Clinic. The Facility Director will be responsible for maintaining a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, and any problems encountered during the drill as well as be responsible for noting that the Department has waived Mission New Life's requirement to sound a fire alarm or smoke detector because of the disruption this would cause Church staff and other occupants of the building at the time (for example, worshipers or attendees at a memorial service). The Board will hold the Project Director/Facility Director accountable for holding fire drills at at the First Church Clinic at least once a month. |
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
Based on a review of administrative documentation it was determined that the project failed to make the annual report available to the public.
The findings were:
During the review of the project's policy manual on August 27, 2009 the project did not make the annual report available to the public within six months from the end of the project's fiscal year for 2008. The facility fiscal year runs from January to December each year.
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Plan of Correction
The Project Director presented an Annual Report for Year 2008 to the Board on September 18, 2009. The Board approved the Year 2008 Annual Report and authorized its publication. The Project Director will advertise the availability of the Year 2008 Annual Report in the Lancaster Newspapers, the Lancaster Law Review, the Patriot News, and the Dauphin County Reporter. The Board will hold the Project Director accountable for publishing future Annual Reports within six months of the end of each fiscal year. |
709.24(a)(2) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Treatment models utilized by the project.
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Observations
Based on the review of the administrative manuals during the annual onsite licensing inspection the facility failed to document treatment model definitions in the agency manual.
The findings included:
During the onsite inspection the agency manuals were reviewed on August 27, 2009. It was noted during the inspection that the treatment models utilized were named; however, the facility failed to define the treatment models in the agency manual.
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Plan of Correction
The Project Director will review Mission New Life's Policy and Procedures concerning section 709.24 (a)(2) related to treatment models utilized by the project and propose revisions for Board consideration. Upon Board approval, the Project Director will revise Mission New Life Policy and Procedures to include definitions of the stated treatment models. To ensure compliance with 709.24(a)(2) in the future, the Project Director will annually review Mission New Life's Policy and Procedures and propose revisions to reflect the addition or deletion of treatment models in use by Mission New Life counselors. The Board will hold the Project Director accountable for reviewing all Mission New Life policy and procedures at least annually and updating them as necessary and appropriate. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of the policy and procedure manuals the project failed to provide a completed audit by an independent public accountant for the project's fiscal year.
The findings include:
A review of the policy and procedure manual was conducted on August 27, 2009. The facility failed to provide a completed audit by the end of the 2008 fiscal year. The facility fiscal year runs from December to January of each year.
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Plan of Correction
When Mission New Life incorporated as a non-profit, it changed its fiscal year from January through December to July through June. July of 2008 through June of 2009 was Mission New Life's first full fiscal year as a non-profit organization. The Project Director will procure an independent public accountant to conduct an audit of Mission New Life's financial activities during Fiscal Year 2008-2009. This will be done within six months of the end of the fiscal year as required in section 709.25(a) of the Department Regulations. The Board will hold the Project Director accountable for procuring an annual audit of financial activities associated with the project's drug and alcohol abuse services. |
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 the review of client records the facility failed to document an aftercare plan in one of two records reviewed.
The findings include:
Based on the review of two client records on August 28, 2009, the facility failed to document an aftercare plan in one of two records reviewed, specifically record #1.
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Plan of Correction
To insure that Mission New Life is in compliance with section 709.93(a)(9) of the Department Regulations, the Project Director will instruct counselors at the First Church Clinic to prepare an Aftercare Plan for all clients successfully completing its drug and alcohol treatment program. The Project Director will monitor the charts of all clients successfully completing to insure that this policy is being carried out. |
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
Based on the review of client records the facility failed to complete a discharge summary within one week of the client's discharge in one of two records.
The findings include:
Two client records were reviewed on August 28, 2009. Discharge summaries were required in two client records. The facility failed to document a discharge summary within seven days of the client's discharge. Client #1 was discharged on 5/31/2009. The discharge summary was not completed until 8/29/2009.
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Plan of Correction
To insure that Mission New Life is in compliance with section 709.93(a)(10) of the Department Regulations, the Project Director will instruct counselors at the First Church Clinic to prepare all Discharge Summaries within seven days of discharge. The Project Director will monitor the charts of all discharged clients to insure that Discharge Summaries are completed within seven days of discharge. |
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 the review of client records, the facility failed to document follow-up information in one of two records reviewed.
The findings include:
Based on the review of two client records on August 28, 2009, the facility failed to document follow-up per the facility's policy in one of two records reviewed. The facility's policy stated they would conduct client follow-up at 30 days. Client #1 was discharged on 5/31/2009; follow-up information was not documented until 7/29/2009.
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Plan of Correction
To insure that Mission New Life is in compliance with section 709.93(a)(11) of the Department Regulations, the Project Director will instruct counselors at the First Church Clinic to follow up with all clients within 30 days of the client's discharge. The Project Director will monitor the charts of all discharged clients to insure that attempts to follow up with discharged clients are made within 30 days and documented. Finally, the Project Director will review Mission New Life Policy and Procedures regarding follow-ups to reduce the number of follow-up contacts required and make necessary policy and procedural adjustments to accomplish these changes without compromising Department regulations. The Board will hold the Project Director accountable for making necessary policy and procedures changes. |