INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 21, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mid-Atlantic Rehabilitation Services - A.T.P. 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of twelve personnel records, the facility failed to develop written individual training plans for five employees annually with input from both the employee and the supervisor according to the facility ' s policy that individual training plans are to be completed each January.
Employee #5 was hired on August 19, 2020. Employee #5 ' s individual training plan was not completed until February 13, 2022.
Employee #6 was hired on March 9, 2022. Employee #6 ' s individual training plan was not completed until March 17, 2022.
Employee #7 was hired on May 3, 2021. Employee #7 ' s individual training plan was not completed until April 1, 2022.
Employee #9 was hired on May 1, 2022. Employee #9 ' s individual training plan was not completed until March 7, 2022.
Employee #11 was hired on April 12, 2021. Employee #11 ' s individual training plan was not completed until April 27, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Multiple training plan development sessions will be held in conjunction with annual in-service meetings to review and complete training plans during the month of January. These will be facilitated and completed by the MARS Human Resources Director in conjunction with Clinical Supervisor staff. |
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 twelve personnel records, the facility failed to ensure one counselor received the 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 within the first year of employment.
Employee #7 was hired as a counselor on May 3, 2021 and was current in that position at the time of the inspection. Employee #7 did not have documentation of receiving the minimum 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 16, 2021 licensing inspection.
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Plan of Correction
Employee #7 will completed Basic Hiv and TB/STI/Hep training by the end of January. Human Resources Director will audit all personnel files by 12/12/22. Any staff that have not completed TB/STI/Hep or Basic Hiv training will be informed of their need to attend via email (Supervisors will be informed via email as well as the individual who needs the training. Monthly audits of personnel files and monthly notifications of staff will be completed by Human Resources Director. TB/STI/Hep training is scheduled internally on 1/12/22. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of twelve personnel records, the facility failed to develop annual written individual staff performance evaluations, that were reviewed and signed by the employee in two records reviewed.
Employee #11 was hired as a counselor on April 12, 2021 and is current in that position. Employee #11 was first hired at the facility in August 24, 2020. The annual staff performance evaluation dated August 1, 2022, indicated it was reviewed verbally but did not include a written employee signature.
Employee # 8 was hired at the facility as a counselor on February 3, 2021 and is still current in that position. Employee #8 ' s annual staff performance evaluation dated February 1, 2022, indicated it was reviewed verbally but did not include a written employee signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #11 and Employee #8 will review annual reviews with supervisor a second time and provide a written signature. Human Resources will provide all supervisors with information that all annual reviews must be signed with written signatures and supervisors will sign an attestation that they are aware. Human Resources Director will audit personnel files monthly to ensure signatures are present on annual reviews. |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the dated signature of the client.
Client #7 was admitted on June 9, 2022 and discharged on July 14, 2022. Client #7 record had an informed and voluntary consent for the disclosure of information to their funding source that had " verbal consent " written on it, but there was no dated signature of the client. The facility reported billing while the client was at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All documents that required signatures were sent to clients for signature utilizing smallpdf (at the time of this individuals admission). Documents were not returned. As of 7/1/22 MARS has switched to utilization of docusign for client signatures. Assessment Coordinator and Director of Quality Assurance will work to audit all release of information forms for compliance with client signatures. This occurs on a weekly basis. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of seven client records, the facility failed to document written acknowledgement by clients that they have been notified of their client rights in two records reviewed.
Client #5 was admitted on June 22, 2021 and was discharged on April 6, 2022. The client rights notification stated verbal consent and was missing the written acknowledgement.
Client #7 was admitted on June 9, 2022 and discharged on July 14, 2022. The client rights notification stated verbal consent and was missing the written acknowledgement.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All documents that required signatures were sent to clients for signature utilizing smallpdf (at the time of this individuals admission). Documents were not returned. As of 7/1/22 MARS has switched to utilization of docusign for client signatures. Assessment Coordinator and Director of Quality Assurance will work to audit for compliance with client signatures. This occurs on a weekly basis. |
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 seven client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in three records reviewed.
Client #2 was admitted on March 28, 2022 and was current at the time of the inspection. Client #2 had a treatment and rehabilitation plan dated June 24, 2022, and the next update was due by August 24, 2022, but was not completed until September 2, 2022.
Client #4 was admitted on June 16, 2022 and was current at the time of the inspection. Client #4 had a treatment and rehabilitation plan dated August 28, 2021, and the next was dur no later than October 28, 2021; however, it was not documented until November 6, 2021. The next update was due no later than January 6, 2022; however, it was not documented until January 15, 2022. The next update was due March 15, 2022; however, it was not documented until May 7, 2022. The next update was due no later than July 7, 2022; however, it was not documented until August 13, 2022. The next update was due October 13, 2022; however, it was not documented until November 19, 2022.
Client #5 was admitted on June 22, 2021 and was discharged on April 6, 2022. Client #5 had a treatment and rehabilitation plan update on July 13, 2021, and the update was due no later than September 13, 2021; however, it was not documented until October 28, 2021. The next update was due no later than December 28, 2021; however, there wasn ' t documentation of any updates prior to discharge.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the licensing inspections that took place on November 16, 2021; October 19, 2020; November 5, 2019; October 10, 2018; November 28, 2017; and October 14, 2016.
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Plan of Correction
Beginning in 8/22 and on a weekly basis the Director of Quality Assurance has begun auditing all active client records for Treatment Plans and Treatment Plan updates. Each clinician receives an email update on due dates for treatment plans for each client. Quality Assurance director will continue this practice moving forward to ensure timely completion. |
709.17(a)(3) 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:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of both personnel records and client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for updating treatment and rehabilitation plans was submitted and approved by the Department for the October 19, 2020; November 5, 2019; October 10, 2018; November 28, 2017; and October 14, 2016, licensing inspections was again found to be a deficiency in the November 21, 2022, annual licensing inspection.
A plan of correction for employees receiving the minimum 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training was submitted and approved by the Department for the October 19, 2020, licensing inspection was again found to be a deficiency in the November 21, 2022, annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Within the past several months MARS has promoted a clinical supervisor to the position of Director of Quality Assurance. The Director of Quality Assurance will be responsible for all implementation and ongoing monitoring of corrective action plans submitted to DDAP to ensure their implementation and completion, in addition to other quality improvement duties. |