INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 29, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mazzitti and Sullivan Counseling Services, Inc. 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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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that exits from rooms and from the nonresidential facility are unobstructed.
The findings include:
A physical plant inspection was conducted on April 29, 2015.
The facility failed to ensure that the emergency exit in the basement of the facility was unobstructed. The exit was obstructed by a cardboard box and also a vacuum.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will order the building to be inspected by office administrative staff weekly to insure that all exits from all floors will be free from obstructions. Documentation will be kept in the facillty maintanence binder. The facility director will be responsible for this action. The order will be initialted 5/22/15. |
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 review of the facilities fire drill logs, the facility failed to conduct fire drills at least once a month and maintain a written fire drill record including the amount of time it took for evacuation, as required by regulation.
The findings include:
The fire drill logs were reviewed on April 29, 2015. The facility failed to document an unannounced fire drill for the month of July, 2014. Additionally, for the months of May 2014, September 2014, and November 2014 the facility failed to document the amount of time it took for evacuation of the unannounced fire drills held those months.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will document a quarterly reviews of firedrill logs at each facility he or she is responsible for.The facility director will re train the office administration on fire drill porcedures and proper ducumentation in fire drill log. Office administration is responsible for initiating fire drills and documenting time ,date and length of time to evacuate and return time. The facility director is responsible for this area. |
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, the project failed to make the annual report available to the public.
The findings include:
Based on a review of administrative documentation, the project failed to provide the verification that an annual report has been made available to the public.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Annual report will be posted on the company website following the the approval of the Board of Directors.The agency director is resposnsible for this action. The annual report will be posted by 1/31, since the company runs on a calendar year. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to identify the specific information to be disclosed in three of eleven records. Additionally, the facility failed to document the date, event or condition upon which the consent will expire in one of eight records.
The findings include:
Eleven client records were reviewed on April 29, 2015. All were reviewed for informed and voluntary consent forms. The facility failed to document the specific information to be disclosed in three client records, specifically records #3, 7, and 11. Additionally, the facility failed to document the date, event or condition upon which the consent will expire in one client record, specifically record #7.
Client #3 was admitted into treatment on 8/22/14 and was still active at the time of inspection. The facility failed to specify the information to be disclosed on one consent to release information.
Client #7 was admitted into treatment on 7/16/14 and still active at the time of inspection. The facility failed to specify the information to be disclosed and failed to document the date, event or condition upon which the consent will expire on two consents to release information.
Client #11 was admitted into treatment on 5/22/14 and discharged on 7/10/14. The facility failed to specify the information to be disclosed on one consent to release information.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The staff involved in the review at this facility will be re trained in accurately identifying information that is to be disclosed and the time frame or conditions upon which the consents will expire. The facility director is responsible for the re training which will occur 5/29/15 and the clinical supervisor will be responsible for monthly reviews of records to ensure this action is occurring.If client #3,7,11 are active, the new consent to release information will be offered to the client to sign and place in the chart. |
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 a review of client records, the facility failed to document a treatment plan update at least every 60 days in five of eleven client records reviewed.
The findings include:
Eleven client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on April 29, 2015. The facility failed to document a treatment plan update at least every 60 days in client records #1, 2, 4, 6, and 8.
Client # 1 was admitted on 8/22/14 and still active at the time of licensing. The last two treatment plan updates for client #1 were completed on 2/26/15 and 12/29/14. The actual due dates for those updated treatment plans would have been 2/24/15 and 12/26/14.
Client # 2 was admitted on 12/11/14 and still active at the time of licensing. A comprehensive treatment plan was completed for the client on 12/16/14. There was no documented treatment plan update in the clients' chart.
Client # 4 was admitted on 10/6/14 and discharged on 1/23/15. A comprehensive treatment plan was completed for the client on 10/13/14. There was no documented treatment plan update in the clients' chart.
Client # 6 was admitted on 5/14/14 and discharged on 9/26/14. A comprehensive treatment plan was completed for the client on 5/14/14. There was no documented treatment plan update in the clients' chart.
Client #8 was admitted on 6/4/14 and discharged on 12/8/14. The last two treatment plan updates for client #8 were completed on 7/3/14 and 9/12/14. The facility failed to document a treatment plan update which was due on 11/12/14.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will re train staff involved at this facility on timely completions of the treatment plans. Training will occur on 5/29. The clinical director will be responsible for quarterly reviews of records to insure the treatment plans are completed within the 60 days or document as to why it didn't occur. she will report directly to the agency leadership. Treatment plans for client 1 and 2, if still active will have timely treatment plans completed and submitted to their supervisors for review on a monthly basis. |
709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to ensure that a complete record was documented in seven of eleven client records reviewed.
The findings include:
Eleven client records were reviewed for documentation of a complete client record during the renewal inspection on April 29, 2015. The facility failed to document a complete record in client records #1, 2, 4, 5, 6, 10, and 11.
Client #1 was admitted on 8/22/14 and still active at the time of inspection. The record of service for the client indicated that the client attended an individual counseling session on 12/4/14. A progress note was not documented in the client's record for this individual counseling session.
Client #2 was admitted on 12/11/14 and still active at the time of inspection. The record of service for the client indicated that the client attended group counseling sessions on 3/6/15 and 12/30/14. A progress note was not documented in the client's record for these group counseling sessions. Additionally, the facility failed to document a case consultation in this client's chart.
Client #4 was admitted on 10/6/14 and discharged on 1/23/15. A progress note documented for a group counseling session on 12/18/14 was not documented on the record of service. Additionally, a progress note documented for an individual counseling session on 11/19/14 was not documented on the record of service.
Client #5 was admitted on 11/18/14 and discharged on 1/16/15. The facility failed to document an after-care plan and follow-up information in this clients chart.
Client # 6 was admitted on 5/14/14 and was discharged on 9/26/14. The record of service for the client indicated that the client attended group counseling sessions on 5/15/14, 5/19/14, 5/20/14, 5/23/14, 6/4/14, 6/30/14, 7/2/14, 7/9/14, and 7/14/14. No progress notes were documented in the client's record for these group counseling sessions. Additionally, progress notes documented for group counseling sessions on 8/4/14, 8/25/14, 8/18/14, 7/10/14, and 6/5/14 were not documented on the record of service in the clients' chart.
Client # 10 was admitted on 4/28/14 and discharged 11/10/14. The facility failed to document a case consultation which was due in August of 2014. Additionally, a progress note was found for 5/19/14, but was not documented on the clients' record of service.
Client # 11 was admitted on 5/22/14 and discharged on 7/10/14. The record of service for the client indicated that the client attended an individual one hour phone session. The facility failed to document a progress note for this session in the clients' chart.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will be responsible for re training the staff involved at this site for the licensing visit on documenting a complete record of service for each client served on 5/29/15. The clinical supervisor will be responsible for monthly inspections of client records for the staff involved and document to the facility director the outcome of that inspection. If client chart 2 is still active the therapist will review the case with staff and completed the case consult. |