INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 15, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of 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
|
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of four personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one of two applicable records reviewed.
Employee # 2 was hired as a counselor on August 28, 2023 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until March 11, 2024.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Following the hiring of the employee identified in this citation, Mazzoni Center has instituted an agency-wide new process for onboarding new employees. For all new employees on their first day of employment they receive an orientation to the policies and procedures of the agency and are set up with a HealthStream learning account where they are able to take all required trainings including Fire Safety. Moving forward Open Door Counseling Director of Behavioral Health will review completed trainings to assure that all new staff complete fire safety certification within their first week of employement. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records and a discussion with facility staff, the facility failed to ensure that one staff was trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 2 was hired as a counselor on August 28, 2023 and is current in that position. Employee # 2 began working shifts in August 2023 but was not trained to perform assigned tasks during emergencies until March 11, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Following the hiring of the employee identified in this citation, Mazzoni Center has instituted an agency-wide new process for onboarding new employees. For all new employees on their first day of employment they receive an orientation to the policies and procedures of the agency and are set up with a HealthStream learning account where they are able to take all required trainings including Emergency Preparedness Certification. Moving forward Open Door Counseling Director of Behavioral Health will review completed trainings to assure that all new staff complete Emergency Preparedness certification within their first week of employement. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
|
Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The project's last annual financial audit was for the fiscal year ending June 30, 2022.
This is a repeat citation from the April 3, 2023 annual licensing renewal inspection.
These findings were reviewed with the project staff during the licensing process.
|
Plan of Correction
Mazzoni Center has engaged the independent auditor, Clifton Larson to conduct the FY24 fiscal audit. Due to the delayed completion of the previous FY audit, the current audit has been delayed. The Executive Financial Officer has been working closely with the auditing firm to complete the audit. It is in the final stages with anticipated completion of the FY24 audit by 6/15/24 by the auditing firm. Upon completion of the FY24 audit, Mazzoni Center is on back on track with fiscal reporting. The initial delay for FY22's audit was due to staffing turnover. Current Executive Financial Officer has been in this role since November 2022 and as such, turnover is not an impact moving forward. |
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure that personnel records contained an annual written performance evaluation that was reviewed and signed by the employee in two of three applicable personnel records reviewed.
Employee # 4 was hired as a counselor on August 15, 2022 and is current in that position. The annual written performance evaluation dated September 15, 2023 was not signed by the employee.
Employee # 6 was hired as a counselor on September 15, 2021 and is current in that position. The annual written performance evaluation dated September 13, 2023 was not signed by the employee.
This is a repeat citation from the April 3, 2023 annual licensing renewal inspection.
These findings were reviewed with the project staff during the licensing process.
|
Plan of Correction
From 4/9/2024 and onward, Open Door Counseling at Mazzoni Center Director of Behavioral Health will require that all annual performance evaluations have hard copies that are printed and signed in person by each employee. This will be monitored and reviewed for all yearly evaluations by the Director of Behavioral Health. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including that the project may not discriminate in the provision of services on the basis of ethnicity in all five of five applicable records.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The information provided in this citation will be forwarded to Executive Medical Officer who will be responsible for supervising new management within the department. Upon the hire of a new Director of Behavioral Health, the Director will be tasked with updating our anti-discrimination policy to include the provision of services on the basis of ethnicity. Current clients who have completed previous forms will be notified of the change and sent the updated forms to sign. This will occur no later than 7/1/24. |
709.92(a)(3) 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:
(3) Proposed type of support service.
|
Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in four of five applicable client records reviewed.
Client # 3 was admitted on October 12, 2023 and was discharged on December 20, 2023. The individual treatment and rehabilitation plan was completed on November 13, 2023; however, the plan did not include documentation of the proposed type of support services.
Client # 5 was admitted on August 9, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 28, 2023; however, the plan did not include documentation of the proposed type of support services.
Client # 6 was admitted on July 6, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 2, 2023; however, the plan did not include documentation of the proposed type of support services.
Client # 7 was admitted on January 3, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 9, 2024; however, the plan did not include documentation of the proposed type of support services.
These finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The information provided in this citation will be forwarded to Executive Medical Officer who will be responsible for supervising new management within the department. Upon the hire of a new Director of Behavioral Health, they will be tasked with updating our department's Treatment and Rehabilitation Plan forms to include connecting clients with support services that are separate from the treatment they are receiving at Mazzoni Center. The Director of Behavioral Health will review these new documents with all present and new staff completing these forms and provide necessary training as applicable. This will occur no later than 7/1/24. |
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 are reviewed and updated at least every sixty days in two of three applicable client records reviewed.
Client # 1 was admitted on February 14, 2022 and was discharged on September 12, 2023. A treatment plan update was completed on June 20, 2023, and the next treatment plan update was due no later than August 20, 2023; however, no additional updates were completed prior to the date of discharge.
Client # 6 was admitted on July 6, 2023 and was active at the time of the inspection. A treatment plan update was completed on December 19, 2023, and the next treatment plan update was due no later than February 19, 2024; however, no additional updates were completed prior to the inspection.
This is a repeat citation from the April 3, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Mazzoni Center Director of Behavioral Health will create a tracking system to monitor all current client's treatment plan due dates. They will review this information with staff during weekly supervision meetings to assure that all Treatment Plans are completed no later than 60 days from the previous plan. This will occur no later than 7/1/24.
Client #6 is no longer actively receiving services with us. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information every 90 days during the first year and annually thereafter, per facility policy, in three of six applicable records reviewed.
Client # 1 was admitted on February 14, 2022 and was discharged on September 12, 2023. There was no documentation of a case consultation in the record.
Client # 5 was admitted on August 9, 2023 and was active at the time of the inspection. There was no documentation of a case consultation in the record.
Client # 6 was admitted on July 6, 2023 and was active at the time of the inspection. There was no documentation of a case consultation in the record.
This is a repeat citation from the April 3, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Typically all case consultation notes between therapists, supervisors, and psychiatrist are kept in supervision files that are separate from client medical records. Moving forward, all records regarding case consultation between therapist and supervisor and therapist with psychiatrist will be documented in each client's individual medical records chart. All staff will be notified and trained regarding this during the month of April of 2024 and this procedure will take effect on 7/1/24. The new Director of Behavioral Health will be responsible for monitoring that this information is placed in all client charts. |