INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9 - 10, 2012 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.
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Plan of Correction
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document an annual evaluation of the overall training plan.
The findings include:
The policy and procedure book was reviewed on July 9, 2012. Per the agency policy and procedure manual, an annual evaluation of the training plan will be completed at the end of the facility's training year, December 31. The regulation requires an annual evaluation of the overall training plan to be completed as a component of a staff development program. The facility failed to document the completion of an annual evaluation of the overall training plan for the January 1, 2011 - December 31, 2011 training year.
An interview with the project/facility director on July 9, 2012 confirmed the findings.
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Plan of Correction
The Agency Director is responsible for the annual evaluation of the overall training plan. The Agency Director has completed the annual evaluation of 2011 overall training plan as of July 20, 2012. The Agency Director submitted the 2011 Evaluation of Training to the Board of Directors and it was approved. The agency director will be responsible for submitting the annual evaluation of training plan in January of each year to the Board of Directors for approval.
Date of Completion 7/20/12 |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill records were reviewed on July 10, 2012. The fire drills conducted from August 26, 2011 - June 12, 2012 were reviewed. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility only documented front/back door during fire drills for the following months; October 2011, November 2011, December 2011, January 2012, February 2012, March 2012, April 2012, May 2012 and June 2012.
An interview with the project/facility director on July 11, 2012 confirmed the findings.
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Plan of Correction
The Agency Director has reviewed with all staff the procedures to be followed during a fire drill. The Agency Director trained staff on July 20 2012. The agency director review with full staff, the areas out of compliance with regards to fire drills, at each of our office sites. The use and preparation of alternate exit routes and multiple time frames for drills. The office staff or clinical staff in charge will document fire drills. The Agency Director is responsible for the area of compliance. The agency director will review the fire drill logs quarterly to ensure the drills are being carried out in compliance with Commonwealth of Pa regulations
Date of Completion 8/31/12 |
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 the facility's 2011 annual report, the facility failed to make it available to the public.
The findings include:
The 2011 annual report was reviewed on July 10, 2012. Per the State Standards, if the facility is publicly funded, the facility shall make available to the public the facility's annual report. As of the date of the licensing inspection, the 2011 annual report was not made available for the public to review. An interview with the project director/facility director on July 10, 2012 confirmed the findings.
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Plan of Correction
The Agency Director is responsible for making the annual report available for public review. The report was completed and approved on June 29, 2012 and sent to Website Programmer to enter on site. That task was not completed. Agency Director ordered the annual report to be mailed to our mailing list of referral sources on July 20, 2012. The Agency Director is responsible for the oversight of this regulation and will ensure the report is sent each year before June 30.
Date of Completion 7/20/12 |
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 a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in eight of ten client records.
The findings include:
Ten client records were reviewed on July 10, 2012. A psychosocial evaluation was review in eight client records, #1, 2, 3, 4, 5, 6, 7 and 8. An interview with the project/facility director on July 10, 2012 confirmed the findings.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's assets/strengths, coping mechanisms, support systems, negative factors towards treatment and the counselor conclusions/impressions of the client.
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Plan of Correction
The Agency Director is responsible for oversight. Although there was significant documentation within the Clinician's Assessment section of the bio-psycho-social (BPS), the licensing specialist determined that 8 of 10 were not up to standards. The Agency Director will train clinical staff on completing the Clinician's Assessment section of the BPS to PA Dept of Drug/Alcohol Program standards. The utilization review staff person will document compliance with monthly review of clinical records. Utilization review staff will provide reports to the Agency Director regarding progress with this area of compliance. Date of Completion 8/31/2012. |
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 treatment plan updates in four of eight client records.
The findings include:
Eight client records were reviewed on July 10, 2012. Six of the eight client records were reviewed for treatment plans, #1, 2, 3, 4, 5 and 6. Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days, #1, 3 and 7. Treatment plan updates failed to identify the client's progress as it related to the the goals identified in the individualized treatment and rehabilitation plan. In addition, new goals were identified in the treatment plan update without documenting the progress of previous goals identified, #4.
Client #1's comprehensive treatment plan was documented on February 10, 2012 and their treatment plan update was to be completed by April 10, 2012. Client #1's treatment plan update was documented on May 1, 2012, 21 days from required treatment plan update.
Client #3's comprehensive treatment plan was documented on January 26, 2012 and their treatment plan updates was to be completed by March 26, 2012 and May 26, 2012. The first update was documented May 29, 2012, three days from the required treatment plan update and the second update was documented on June 4, 2012, eight days from the required treatment plan update.
Client #7's comprehensive treatment plan was documented on March 5, 2012 and their treatment plan update was to be completed by May 5, 2012. Client #7's treatment plan update was not documented as of the date of their discharge May 22, 2012.
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Plan of Correction
The Agency Director will instruct the staff on July 20, 2012 regarding treatment plan updates need to be completed every 60 days. The Agency Director will instruct the utilization review staff to focus on treatment plan updates and document progress in this regulation. The utilization review staff will report compliance wtih treatment plan updates to the agency director. The agency director will address clinicians who are not maintaining compliance with this regulation through supervisor counseling. The Agency Director is responsible for ensuring this regulation is in compliance. Date of Completion 9/30/12 |
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
Based on a review of client records, the facility failed to prepare aftercare plan in accordance with the regulations in one of two client records.
The findings include:
Eight client records were reviewed on July 10, 2012. Two discharge client records were required to have documentation of a aftercare plan, #6 and 9. The following components are required to be documented on the aftercare plan; goals with time frames, support services, contact person and the reentry process. The facility failed to include time frames with the goals, contact person and reentry process on the aftercare plan for client #6. Client #6 was admitted on January 27, 2012 and discharged on March 30, 2012. An interview with the project/facility director on July 10, 2012 confirmed the findings.
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Plan of Correction
The Agency Director trained the specific staff that did not complete aftercare plans within compliance. The training included, goals with time frames, support services, contact persons and re-entry. The utilization review staff will monitor clinical records monthly at each facility monthly. Reports on clinical documentation compliance will be given to the Agency Director. Date of Completion 7/27/12 |
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
Based on a review of client records, the facility failed to document a discharge summary within one week of discharge in two of two client records.
The findings include:
To client records were reviewed on July 10, 2012. Per agency policy, discharge summaries are due within one week of discharge. Discharge summaries were required in five client records, #6, 7, 8, 9 and 10. The facility did not document a discharge summary within one week of discharge in client records # 8 and 10.
Client # 8 was admitted on February 24, 2012 and was discharged on April 4, 2012. The discharge summary was due by April 11, 2012. The discharge summary was completed on April 24, 2012.
Client # 10 was admitted on February 6, 2012 and was discharged on May 4, 2012. The discharge summary was due by May 11, 2012. The discharge summary was completed on May 18, 2012.
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Plan of Correction
The Agency Director reviewed and trained staff regarding time frames for completing discharge summaries on 7/27/12. The utilization review staff will monitor clinical charts at each facility monthly and report to the Agency Director regarding therapist compliance with this regulation. The Agency Director is responsible for the compliance in this area. Date of Completion 7/27/12 |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of the client records, the facility failed to provide a physician signature on treatment plans and treatment plan updates in one of two client records.
The findings include:
Ten client records were reviewed on July 10, 2012. Two of ten client records reviewed identified medical assistance funding for these clients. Clients with medical assistance funding are required to have a physician signature on the treatment plans and the treatment plan updates. This documentation was missing in record # 2.
Client record #2 - The client was admitted on February 6, 2012 and the treatment plan was completed on February 29, 2012. The physician signature was missing on the treatment plan update.
An interview with the project/facility director on July 10, 2012 confirmed the findings.
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Plan of Correction
The Agency Director reviewed and trained all staff on Medical Assistance regulations regarding having the Medical Director review and sign off on treatment plans of charts whose services are funded by PA Dept of Welfare (DPW) within 15 days of treatment. The utilization review staff will monitor DPW funded client charts to assure compliance to this regulation. The Agency Director is repsonible for compliance in this area. Date of Completion 7/20/2012 |