INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 28, 2009 licensure renewal inspection. The follow-up inspection was conducted on March 1, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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
March 30, 2010.
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Plan of Correction
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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
Follow-up inspection conducted on March 1, 2010 and the policy and procedure manual pertaining to general safety and emergency procedures was requested. The licensing specialist was informed by the Administrative Secretary that the facility was currently working on the general safety and emergency procedures and the documentation was not ready for review for this site.
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Plan of Correction
The Project Director is currently revising Mission New Life's policy and procedures related to the evacuation and transfer of clients and staff in case of an emergency. He is also drafting an emergency preparedness plan to complement policy and procedures related to evacuation and transfer of clients and staff in case of emergency. The Project Director in collaboration with the Facility Director at Thirty-Nine West Vine will meet with the entire Mission New Life staff to review the revised policy and procedures and emergency preparedness plan. This review session will serve both for training purposes as well as to gain staff feedback for fine tuning safety and emergency procedures as well as the emergency preparedness plan. Proposed revisions will be brought to the Board at its next regular meeting scheduled for May 14, 2010. Upon Board approval, the Project Director will revise Mission New Life Policy and Procedures to include the approved policy and procedures for evacuating and transferring clients and staff in case of emergency and the revised emergency preparedness plan. To ensure compliance with 705.27(4)(i) in the future, the Project Director in collaboration with the Facility Director will annually review Mission New Life's Policy and Procedures for evacuation and transfer of clients and staff as well as Mission New Life's Emergency Preparedness Plan with the entire staff to determine whether Mission New Life is in compliance and whether improvements can be made. 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. |
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
Follow-up inspection conducted on March 1, 2010 and the policy and procedure manual pertaining to general safety and emergency procedures was requested. The licensing specialist was informed by the Administrative Secretary that the facility was currently working on the general safety and emergency procedures and the documentation was not ready for review for this site.
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Plan of Correction
The Project Director is currently revising Mission New Life's policy and procedures related to the evacuation and transfer of clients and staff in case of an emergency. The revised policy and procedures will include assignments of staff during emergencies. The Project Director in collaboration with the Facility Director at Thirty-Nine West Vine will meet with the entire staff to review revised policy and procedures. This review session will serve both for training purposes as well as to gain staff feedback for fine tuning emergency assignments. Proposed revisions will be brought to the Board at its next regular meeting scheduled for May 14, 2010. Upon Board approval, the Project Director will revise Mission New Life Policy and Procedures to include the approved policy and procedures for assigning staff during emergencies. To ensure compliance with 705.27(4)(ii) in the future, the Project Director in collaboration with the Facility Director will annually review Mission New Life's Policy and Procedures for assigning staff during emergencies with the entire staff to determine whether Mission New Life is in compliance and whether improvements can be made. 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. |
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
At time of review, the facility failed to provided documentation of monthly fire drills.
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Plan of Correction
Since the Department's site inspection last August 28, 2009, there have only been 1½ hours of client contact at Mission New Life's First Church Clinic. The First Church Clinic has been used sparingly as a working office and meeting place. Nevertheless, licensure of the First Church Clinic for drug and alcohol treatment is important 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 is currently training a new counselor who will be assigned to the First Church Clinic. The new counselor 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 achieving and maintaining compliance. |
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
Follow-up inspection conducted on March 1, 2010 and the policy and procedure manual pertaining to treatment models utilized by the project was requested. The licensing specialist was informed by the Administrative Secretary that the policy and procedure manual had not been had not been corrected since last inspection and was not currently ready for review.
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Plan of Correction
The Project Director has drafted a revised statement regarding treatment models utilized by the project. The draft statement was reviewed with the clinical staff on March 25, 2010 and subsequently revised again. Proposed revisions will be brought to the Board at its next regular meeting scheduled for May 14, 2010. Upon Board approval, the Project Director will revise Mission New Life Policy and Procedures to include revised definitions of treatment models utilized. 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
Follow-up inspection conducted on March 1, 2010 and the fiscal audit was requested. The licensing specialist interviewed the accountant and was informed the audit had yet to be completed.
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Plan of Correction
Mission New Life will maintain both records and accounts of all revenues and expenditures. Within three months after the end of a fiscal year, Mission New Life will "close the books" on the fiscal year just completed and prepare a balance sheet and an income and expense statement for the fiscal year. Mission New Life will hire an independent public accountant to audit all financial activities associated with the project's drug/alcohol abuse services and provide an opinion within six months of the end of the fiscal year. Mission New Life will use QuickBooks Online to record income and expenditures as well as prepare balance sheets and income and expense statements. The Project Director will be responsible for achieving compliance. He will work with Mission New Life's independent public accountant and Mission New Life's billing agent to maintain compliance. |
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
At time of review there was no documentation that addressed that the deficiency had been corrected..
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Plan of Correction
Client charts shall be available for inspection at all times. The Project Director will be responsible for achieving and maintaining compliance. |
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
At time of review there was no documentation that addressed that the deficiency had been corrected..
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Plan of Correction
Client charts shall be available for inspection at all times. The Project Director will be responsible for achieving and maintaining compliance. |
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
At time of review there was no documentation that addressed that the deficiency had been corrected..
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Plan of Correction
Client charts shall be available for inspection at all times. The Project Director will be responsible for achieving and maintaining compliance. |