INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection monitoring conducted on April 19, 2022 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:
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in two of two applicable personnel records reviewed.
Employee # 4 was hired as a counselor on September 15, 2021. The personnel record documented that the training in the use of fire extinguishers was not completed until March 28, 2022.
Employee # 5 was hired as a counselor on May 10, 2021. The personnel record documented that the training in the use of fire extinguishers was not completed until April 19, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Mazzoni Center has transitioning onboarding orientation to a new training platform during this evaluation period, which explains the delay in formally training staff using the new platform. All newly hired staff will complete fire extinguisher training during onboarding orientation. Record of this training will be maintained in personnel record. Facility Director will monitor for compliance. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's May 2021 through March 2022 fire drill logs, the facility failed to ensure that unannounced fire drills were conducted at least once a month. There were no fire drills documented for the months of May 2021, June 2021, December 2021, January 2022, February 2022, and March 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the months of May 2021, June 2021, December 2021, January 2022, February 2022, and March 2022, Mazzoni Center was operating remotely due to the COVID pandemic. As such staff and clients were not onsite to hold monthly Fire Drills during this time. However, it is understood that future fire drills must be held on a monthly basis regardless, unless a state of emergency is declared. Mazzoni Center has resumed monthly fire drills and will continue to do so. Facility Director will document and Program Director will monitor for compliance. |
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.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in two of two applicable personnel records reviewed.
Employee # 4 was hired as a counselor on September 15, 2021. The personnel record documented that the training to perform assigned tasks during emergencies was not completed until March 28, 2022.
Employee # 5 was hired as a counselor on May 10, 2021. The personnel record documented that the training to perform assigned tasks during emergencies was not completed until April 19, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Mazzoni Center has transitioning onboarding orientation to a new training platform during this evaluation period, which explains the delay in formally training staff using the new platform. All newly hired staff will complete fire safety and emergency procedures training during onboarding orientation. Record of this training will be maintained in personnel record. Facility Director will monitor for compliance. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 7 was admitted on October 22, 2021 and was discharged on December 13, 2021. There was evidence of a family counseling session with the client's parents on December 13, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the counseling session.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
While verbal consent for this family session was received, the Counselor was reminded of the need to obtain formal written consent in these circumstances. Staff was retrained on this procedure during a meeting on 4/21/22. Clinical Supervisor and Facility Director will monitor compliance on a regular basis through supervision and regular chart audits. Program Director will oversee quality assurance efforts. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the witness at the same time as the client on release of information forms in two of seven client records reviewed.
Client # 2 was admitted on November 24, 2021 and was still active at the time of the inspection. The release of information forms to the emergency contact, the primary care physician and the funding source were signed by the client on November 29, 2021; however, all of the forms were not signed by the witness until November 30, 2021.
Client # 5 was admitted on August 4, 2021 and was discharged on December 30, 2021. The release of information forms to the primary care physician and the funding source were signed by the client on July 28, 2021; however, both forms were not signed by the witness until July 29, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff are now advised to witness forms on the same day that they are completed by clients. Staff now has a better understanding of this regulation to ensure compliance moving forward. Clinical Supervisor and Facility Director will monitor compliance during regular chart audits. Program Director will review and oversee quality assurance efforts. |