INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 26, 2009 through August 27, 2009 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 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 conducted on August 27, 2009, the facility failed to ensure the hot water temperature did not exceed 120F.
The findings include:
A physical plant inspection was conducted on August 27, 2009 at approximately 10:00AM. The hot water temperature registered at 133F in the restroom on the first floor.
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Plan of Correction
The facility director informed the handy man to turn down the hot water heater on 9/18/09. The facility director tested the temp on 9/19/2009. The temp reading was 115F the facility director will be responsible for checking the water temp. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records and staff interview, the facility failed to provide documentation of a signed consent to treatment in six of six client records.
The findings include:
Six client records were reviewed on August 27, 2009. A consent to treatment signed by the client and the staff person at intake was required in six client records. A consent to treatment was not documented in client records, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The faacility director has added a signiture line to the consent to treatemnet form. The facilety director has informed staff of the change on 8/28/09. The Facility Director(FD) will train staff on the change on 9/10/09. A utilization review staff member is now in training to be respnsible for follow up. |
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
Based on a review of client records, the facility failed to provide documentation of a psychosocial evaluation in two of six client records. The facility also failed to document a psychosocial evaluation which included potential or available client support systems in two client records.
The findings include:
Six client records were reviewed on August 27, 2009. A psychosocial evaluation was required in six client records. There was no psychosocial evaluation documented in client records #2 and 3. The psychosocial evaluation documented in client records #5 and 6 did not include potential or available support systems. The potential or available support systems in the psychosocial evaluation documented in client records #1 and 4 were client reported and did not include a clinical assessment.
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Plan of Correction
The FD has added lines to the psycho-socialso therapists can add opinions and statements. Training will be conducted onby the FD regarding the direction given at the licensing visit. A UR staff person will conduct chart audits monthly to insure this area is in compliance. The UR staff person will report to the FD. Training will be conducted on 9/10/09 |
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 provide documentation of a treatment plan update in two of six client records.
The findings include:
Six client records were reviewed on August 27, 2009. Treatment plan updates were required in six client records. Treatment plan updates were not documented in client records #2 and 3. A treatment plan update in client record #2 was due to be completed by August 18, 2009. There was no treatment plan update documented in client record #2 as of August 27, 2009. A treatment plan update in client record #3 was due to be completed by August 14, 2009. There was no treatment plan update documented in client record #3 as of August 27, 2009. The treatment plan update in client record #4 was documented late. This treatment plan update was due to be completed by April 17, 2009; however, it was not documented until April 23, 2009.
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Plan of Correction
The FD will conduct a training on 10/09/2009 regarding this area of non-compliance. The UR staff will then begin to have monthly review of charting to provide feedback to therapists and FD information regarding treatment plan updates. The facility director is responsible for compliance. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to provide documentation of case consultation notes in four of six client records.
The findings include:
Six client records were reviewed on August 27, 2009. Case consultation notes were required in six client records. Case consultation notes were not documented in client records #2, 3, 4 and 6.
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Plan of Correction
The FD will conduct a training on the areas of case consultation non compliance. The FD will instruct the UR staff to review charts monthly to see that case consults are documented as required. The FD is responsible for compliance of this area. |
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 a review of client records and staff interview, the facility failed to document follow-up information in two of three client records.
The findings include:
Six client records were reviewed on August 27, 2009. Follow-up information was required in three client records. Follow-up information was not documented in client records #4 and 6.
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Plan of Correction
The FD will train staff on 10/09/09 regarding the area of non-compliance for follow up. The UR staf person will receive the follow up form from all staff people to make calls for. The ur staff person will report non compliance to the FD. The FD is responsible for compliance in this area. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and staff interview, the facility failed to provide documentation of HIV/AIDS and TB/STD training in two of seven personnel records.
The findings include:
Seven personnel records were reviewed on August 26, 2009. Five personnel records were required to have at least six hours of HIV/AIDS training and at least four hours of TB/STD training documented. HIV/AIDS and TB/STD training was not documented in personnel records #6 and 7. Personnel record #6 was required to have the HIV/AIDS and TB/STD training completed by August 14, 2008. Personnel record #7 was required to have the HIV/AIDS and TB/STD training completed by January 8, 2009.
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Plan of Correction
the FD has scheduled training to begin on 10/09/09 for members of staff that need HIV/AIDS and STD/TB requirements. Using a DOH approved curriculum, the training will occur weekly until hourly reqirements are met. The FD will be responsible for the oversight of the trainings. |