INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 14, 2010 through April 15, 2010 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 and a plan of correction is due on May 10, 2010.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel records, the facility failed to ensure that the clinical supervisor had the required clinical supervision training in one of one personnel records reviewed.
The findings include:
Eight personnel records were reviewed on April 14, 2010. One of the eight was the clinical supervisor and was required to have the clinical supervision training. The facility director was interviewed on April 15, 2010 and she was in agreement that employee #2 did not obtain the required clinical supervision training due to the training not being offered in the Philadelphia area. Employee #2 was hired on 1/14/05 and promoted to clinical supervisor on 3/18/09.
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Plan of Correction
Clinical Supervisor was registered for the required clinical supervision training through BDAP which will be held June 7-11, 2010. Clinical Supervisor will provide documentation of completion of the training, which will be added to her personnel file for future review. Program Director will monitor and ensure completion.
For all future hires or promotions, Program Director will ensure staff has two ears of prior supervisory training. If not, the Clinical Supervisor will be mandated to attend/complete the BDAP Clinical Supervisory training. Program Director will monitor and ensure compliance. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on review of the physical plant tour, the facility failed to ensure that the facility had two exits.
The findings include:
The physical plant inspection took place on April 15, 2010 at approximately 9:30 am. During the inspection it was apparent that there was only one exit located in the lobby of the facility. In an interview with the facility director, it was confirmed that the facility had only one exit.
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Plan of Correction
Mazzoni Center will relocate the D&A facility to another office spacemeeting all physical plant requirementsof Chapter 705 Physical Plant Standards including exiting and having a valid certificate of occupancy by August 31, 2010.
The facility Director will ensure this does not recur by properly notifying the Division of Drug and Alcohol Program Licensure in advance of any intended moves and by forwarding a copy of a valid certificate of occupancy, a copy of the Use and Occupancy Zoni approval, copies of floor plans identifying the location of the counseling offices, group room, exits, smoke detectors, bathrooms and where the clinical records will be kept for approval prior to moving.
The facility Director will be responsible for implementing this corrective action plan by August 31, 2010. |
709.28 (c)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in nine of eleven client records
The findings include:
Eleven client records were reviewed on April 15, 2010. Informed and voluntary consent forms were required in ten client records reviewed.
Client record #1 contained documentation that was a facsimilie was forwarded on 3/8/10 regarding client # 1. The facility failed to have documentation of a signed consent to release informationand the client did not have a signed consent to release form in his record to give the facility permission to send the fax to that person.
Client #2 - The consent to release form signed and dated 2/11/11 ( not valid date) marked that they will be able to send HIV/AIDS related information, Psychiatric records including diagnosis and other information to a health insurance agency. Another consent dated 12/8/09 did not have what was being release marked on the signed consent to release form. This was a health insurance agency. On 4/13/10 a letter was sent out to a claims department and the facility did not have a consent to release from in the clients record to send this letter out to this agency.
Client #3 - There was a consent to release form in the clients record signed and dated 9/14/09 did not have who the consent was for, what the purpose for the consent and what was being released. Another consent signed and dated 9/14/09 did not document what was being released.
Client #4 - The consent to release form signed and dated 3/18/10 marked that they will be able to send HIV/AIDS related information and Psychiatric records including diagnosis. This was a health insurance agency. Another consent dated 12/29/09 did not have what was being release marked on the signed consent to release form.
Client #5 - The consent to release form signed and dated 7/8/09 did not mark what was being released. There were documentation that information was requested for the client pertaining to their health insurance, 1/25/10, 2/26/10, 3/4/10 and 3/31/10.
Client #6 - The consent to release forms signed and dated 1/28/10 and 2/24/10 did not document what is being released. These were health insurance agencies. Also, a consent to release form signed and dated 7/22/09 for the clients doctor did not mark the purpose for the release and what is being released.
Client #9 - The consent to release form signed and dated 9/10/09 marked that they will be able to send HIV/AIDS related information and Psychiatric records including diagnosis.
Client #10 - The consent to release form signed and dated 1/14/10 marked that they will be able to send HIV/AIDS related information, Psychiatric records including diagnosis and other. This was a health insurance agency
Client #11 - The consent to release form signed and dated 8/13/09 did not document the purpose and what is being released. These were health insurance agencies.
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Plan of Correction
Program Director revised current Consent forms to remove general language and change to clear more precise language. For example, "HIV related information" was changed to "HIV/AIDS diagnosis", and "Psychiatric records, including diagnosis" was changed to "Psychiatric diagnosis".
Program Director and Clinical Supervisor will immediately introduce revised forms to staff during supervision meetings with staff. Staff will be instructed to implement changes in procedure immediately. In addition,Program Director will hold in-service training with staff on 6/14/2010 to review together as a group.
Immediately following site inspection on 4/19/10, staff was advised by Program Director to cease from addressing any correspondence "To Whom It May Concern".
On 4/22/10, Client #1 signed a Consent to release form for permission to fax information to outside agency.
Staff completed a new Consent to Release form with Client #2 on 5/11/10 which indiciates the correct date and authorizes permission to release "DSM-IV diagnosis" to health insurance agency. The release dated 12/8/09 is voided due to the updated. The current consent covers permission to facilitate billing for this client. 4/13/10 document was a billing claim form to insurance company, now covered by the current correct release.
Client #3, will have new release form completed by client at next office visit which provides authorization to release DSM-IV diagnosis to health insurance company. Both releases found in chart dated 9/14/09 were intended for insurance companies and will be voided.
Client #4, will have new release form completed by client at next office visit which provides authorization to release DSM-IV diagnosis to health insurance company. Release dated 12/29/09 will be removed from chart.
Client #5 will have new release form completed by client at next office visit which provides authorization to release DSM-IV diagnosis to health insurance company.
Client #6 will have new release form completed by client at next office visit which provides authorization to release DSM-IV diagnosis to health insurance company. Release forms dated 1/28/10 and 2/24/10 will be reviewed and updated with information that indicates the purpose for which information is being released. Release dated 7/22/09 will be changed to indicate the purpose for which information is being released.
Client #9, #10 and #11 are no longer in treatment and therefore can not have corrective action taken.
Clinical Supervisor and Program Director will monitor on an on-going basis for complaince.
Program Director will review with staff on a quarterly basis during in-service meetings to ensure this remains a point of emphasis. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of the facilities policy and procedure manual and client records, the facility failed to document personal histories in accordance with their policy and procedure in four of eleven records reviewed.
The findings include:
Eleven client records were reviewed on April 15, 2010. Personal histories were required in eleven client records. In accordance with the facility's policy and procedure, personal histories are to be completed within 30 days of the client's admission date.
Client #2 was admitted on 12/17/09 and their personal history was completed on 2/18/10.
Client #3 was admitted on 8/6/09 and their personal history did not have documentation of the date of completion.
Client #4 was admitted on 12/29/09 and their personal history was completed on 2/1/10.
Client #9 was admitted on 9/10/09 and their personal history was completed on 12/7/10.
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Plan of Correction
Program Director amended the agency's policy and procedure manual to indicate due date for personal histories to occur before the fifth session, thereby giving adequate time to complete the history even if clients miss appointments.
Program Director reviewed new policy with staff on 4/19/10. Staff will thoroughly document personal histories and all attemtps to complete within specified time frame.
Clinical Supervisor will monitor for compliance. Program Director will review new policies on a quarterly basis at staff meetings, and monitor for compliance on an on-going basis. |
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 the review of the facility's policy and procedure manual and client records, the facility failed to document psychosocial evaluations in accordance with their policy and procedure in seven of eleven records reviewed.
The findings include:
Eleven client records were reviewed on April 15, 2010. Psychosocial evaluations were required in eleven client records. In accordance with the facility's policy and procedure, psychosocial evaluations are to be completed within 30 days of the client's admit date.
Client #2 was admitted on 12/17/09 and their psychosocial evaluation was completed on 2/18/10. Also, the evaluation did not evaluate the client to include support system and coping mechanisms.
Client #3 was admitted on 8/6/09 and their psychosocial evaluation did not have documentation of the date of completion. Also, the evaluation did not document an assessment of the client regarding support systems, coping mechanisms and the counselor's conclusions and impressions about the client.
Client record #4 was admitted on 12/29/09 and their psychosocial evaluation was completed on 2/1/10. Also, the evaluation did not document an assessment of the client regarding the client's assets and strengths, support system and coping mechanisms.
Client record #5 failed to evaluate the client when it came to the client's assets/strengths and support system.
Client record #6 failed to evaluate the client when it came to the client's assets/strengths, support system, coping mechanisms, negative factors that might inhibit treatment and the counselors conclusion/impressions.
Client record #9 was admitted on 9/10/09 and their psychosocial evaluation was completed on 12/7/10. Also, the evaluation did not evaluate the client when it came to their support system.
Client record #11 failed to complete the clients personal history before completing the clients psychosocial evaluations dated 8/13/09. Client was admitted to the program on 8/13/09 and discharged on 12/7/09. Client was only seen once which was the 8/13/09.
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Plan of Correction
Program Director has amended agency's policy and procedure manual to reflect the due date for psychosocial evaluations to be completed by the fifth session, thereby allowing adequate time for missed session that may occur. Staff will thoroughly document all efforts in the client chart.
Program Director held meeting with Clinical Supervisor and staff on 4/19/2010 to review new policy and to review the correct and thorough completion of psychosocial evaluations. Staff will thoroughly complete and comment on client's support systems, assets/strengths, coping mechanisms, counselor's conclusions and impressions about the client.
Clinical supervisor will monitor individual client charts for compliance. Program Director will monitor on an ongoing basis and review quarterly with staff. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of the facility's policy and procedure manual and client records, the facility failed to document comprehensive treatment plans in accordance with their policy and procedure in five of eleven records reviewed.
The findings include:
Eleven client records were reviewed on April 15, 2010. Comprehensive treatment plans were required in eleven client records. In accordance with the facility's policy and procedure, comprehensive treatment plans are to be completed within 30 days of the clients admit date.
Client #2 was admitted on 12/17/09 and their comprehensive treatment plan was completed on 3/16/10.
Client #3 was admitted on 8/6/09 and their comprehensive treatment plan was completed on 12/28/09.
Client record #4 was admitted on 12/29/09 and their comprehensive treatment plan was completed on 2/25/10.
Client record #6 was admitted on 7/23/09 and their Comprehensive treatment plan was completed on 9/10/09.
Client record #9 was admitted on 9/10/09 and discharged on 2/17/10. The client's histories was completed on 12/7/09 and as of the date of their discharge there was no comprehensive treatment plan.
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Plan of Correction
Program Director amended agency's policy and procedure manual to reflect due date for the comprehensive treatment plan to occur by the fifth session in order to better develop a comprehensive plan of treatment taking into account missed sessions after intake.
Staff was informed of this change during a team meeting on 4/19/2010.
Clinical Supervisor and Program Director will oversee on-going compliance. Program Director will revisit with staff during in-service meetings on a quarterly 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 the review of the facility's policy and procedure manual and client records, the facility failed to document treatment plan updates in accordance with their policy and procedure in five of eleven records reviewed.
The findings include:
Eleven client records were reviewed on April 15, 2010. Treatment plan updates were required in five client records. In accordance with the facility's policy and procedure treatment plan updates are to be updated every 60 days after the initial comprehensive treatment plan.
Client #1's treatment plan updates were completed approximately every 90 days instead of every 60 days. Treatment plan updates were completed 4/9/09, 7/13/09, 10/8/09 and 1/4/10. There has been no treatment plan update since 1/4/10.
Client #3's comprehensive treatment plan was completed on 12/28/09 and their treatment plan update was not documented until 3/3/10.
Client #5's comprehensive treatment plan was completed on 7/29/09. The treatment plan updates were completed on 11/5/09, 12/23/09 and 3/17/09.
Client #6's comprehensive treatment plan was completed on 9/10/09. The treatment plan updates were completed on 12/11/09 and 2/24/10.
Client #10's comprehensive treatment plan was completed on 2/1/10 and no treatment plan update was documented in the client record.
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Plan of Correction
Prior policy had Treatment Plan updates occuring 60 days from the date of intake and used the date of intake as the marker for all subsequent updates. Policy and procedures were corrected to indicate due date for Treatment Plan updates is 60 days following Comprehensive Treatment Plan completion.
Program Director will review change with staff at in-service meeting on 6/14/10. Director and staff will review due date and procedures for completing plans within specified time-frame.
Clinical Supervisor and Program Director will oversee changes are implemented and Program Director will ensure on-going compliance. |
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 the review of the facility's policy and procedure manual and the client record, the facility failed to document aftercare plans in two of five discharge records.
The findings include:
Eleven client records were reviewed on April 15, 2010. Aftercare plans were required in three of the five discharge records reviewed. In accordance with facility policy and procedure, aftercare plans will be documented within 30 days of the client's discharge date.
Client record #7 did not have documentation of the client's goals or the contact person for re-entry to the program.
Client record #8 was admitted on 3/24/08 and discharged successfully on 1/6/10. There was no documentation of client's aftercare plan.
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Plan of Correction
Program Director reviewed policy and procedure during clinical team meeting on 4/19/10. Staff was advised on the correct procedure for thoroughly completing Aftercare Plans which includes clear and concise statement of goals, contact information and re-entry procedure.
Clinical Supervisor and Program Director will monitor all discharged client charts for compliance. Program Director will review policy on a quarterly basis at in-service meetings to ensure on-going compliance. |
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 the review of client records, the facility failed to document timely follow-up information in four of five discharge records reviewed.
The findings include:
Eleven client records were reviewed on April 15, 2010. Follow-up information was required in five discharge, #7, 8, 9, 10 and 11. In accordance with the facility's policy and procedure, all follow-ups will be done within 7 days of clients discharge date.
Client #7 was admitted on 10/28/09 and discharged on 1/26/10; no follow-up was documented.
Client #8 was admitted on 3/24/08 and discharged on 1/6/10; no follow-up was documented.
Client #10 was admitted on 1/4/10 and discharged on 3/15/10; no follow-up was documented.
Client #11 8/13/09 and discharged on 12/7/09; no follow-up was documented.
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Plan of Correction
During team meeting on 4/19/10, Program Director met with staff and reviewed policy and procedure for completing client follow-ups post discharge. Initially, Program Director and staff believed discharge letters that were sent to clients constituted follow-up. However, staff were advised of the difference and proprer procedures were discussed for completing follow-ups. Staff is currently prepared and trained to meet this standard.
Clinical Supervisor and Program Director will monitor on-going for compliance. Program Director will review policy/procedure on a quarterly basis during in-service meetings, and will ensure compliance. |
709.14(b)(3) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(3) Change in location of the facility.
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Observations
During the licensing renewal inspection it was found that the facility did not inform the Division on their temporary move to another location.
The findings include:
The licensing renewal inspection took place on April 14, 2010 through April 15, 2010. The licensing specialist was informed by the facility director on April 14, 2010, that the facility moved on July 1, 2009 to a temporary location at 2012 S. 12th St., Philadelphia PA and that it might take an additional 6 months to complete the renovation of their licensed site. Although a letter was sent to the Division on March 11, 2009 indicating that the facility intended to move to a temporary location tentatively in June of 2009, the letter stated that someone would contact the Division with further details at a date prior to the proposed relocation. The facility failed to notify the Division of the move.
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Plan of Correction
Program Director takes responsibility for insufficient communication about the change of location.
Corrective action to address the building fire safety deficiences outlined in P241 will be addressed through correspondence with BDAP in the immediate future.
Program Director will be more clear in notification of change of location as future need arises. |