INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 11, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Open Door Counseling at Mazzoni Center 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were updated at least every 60 days in three of seven client records.
The findings include:
Seven client records requiring an updated treatment and rehabilitation plan were reviewed on February 11, 2016. The facility failed to document the completion of a treatment and rehabilitation plan update in client records #1, #2 and #8.
Client #1 was admitted on June 18, 2015 and was still an active client at the time of the inspection. A comprehensive treatment plan was completed on August 13, 2015. A treatment plan update was completed on October 15, 2015. The second treatment plan update was due by December 15, 2015. The facility failed to document the completion of the second treatment plan update within 60 days as the update was not completed until January 15, 2016.
Client #2 was admitted on April 6, 2015 and was still an active client at the time of the inspection. A comprehensive treatment plan was completed on May 4, 2015. A treatment plan update was completed on July 13, 2015. The second treatment plan update was due by September 13, 2015. The facility failed to document the completion of the second treatment plan update within 60 days as the update was not completed until October 26, 2015.
Client #8 was admitted on June 26, 2015 and discharged on November 3, 2015. A comprehensive treatment plan was completed on July 24, 2015. A treatment plan update was due by September 24, 2015. The facility failed to document the completion of a treatment plan update within 60 days.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Director met with Manager and Clinical Supervisor to review charts for clients #1, #2 and #8 noting the delay in completion of treatment plans. Manager and Clinical Supervisor have addressed this issue with the counselor's directly involved so they are aware of this violation, and correct future plans moving forward within 60 day time frame.
Director held meeting with staff on 2/19/16 to review this policy in order to ensure future compliance with this policy regulation.
Quality Assurance specialist will monitor compliance on an ongoing basis, reporting to the Director on a quarterly basis.
|
709.17(a)(1) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
|
Observations
Based on a review of administrative documentation, the facility failed to comply with the directive issued by the Department requiring the facility to develop and implement policies and procedures for the reporting of unusual incidents.
The findings include:
As per the directive within Chapter 709 Subchapter C enacted on 10/18/2014, the facility was required to develop and implement policies and procedures for the reporting of unusual incidents.
The facility's administrative records were reviewed for documentation of policies and procedures for the reporting of unusual incidents on February 11, 2016. As of the date of the inspection, the facility did not developed policies and procedures for the reporting of unusual incidents.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Director added policy 709.34 that addresses the reporting of Unusual Incidents to the Department. The facility's manual was updated to reflect the new policy.
In addition, training was held with Manager, Clinical Supervisor and staff on 2/18/16 to review this policy to ensure compliance.
Human Resources Director has added this policy to orientation for all new staff hired after this date.
Director will monitor for ongoing compliance with this regulation. |