INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on June 26-28, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Men and Women for Human Excellence 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on the review of the plan documenting the qualifications and training of staff presented to Division staff during the inspection, the facility failed to document required information on the staffing form document in a timely manner.
The findings included:
The onsite licensure renewal inspection was conducted June 26-28, 2012. The "Staffing Requirements Facility Summary Report" form was presented initially on June 26 upon arrival but contained incomplete and incorrect information. The Project Director was initially not correctly identified. Documentation on the form did not address required information for all current staff. The form was handed back to the facility director on at least two different occasions. A completed and corrected form was not submitted to Division staff until June 28, 2012 near the end of the inspection.
The finding was reviewed with the Clinical Supervisor and Facility Director and was not disputed.
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Plan of Correction
For future onsite licensure renewal inspections, the Program Director shall complete the "Staffing Requirements Facility Summary Report" form in a timely manner and present such to Division staff during the inspection. Information documented shall be complete and actuate. Prior to completing the form, the Program Director shall review the Standards ensure compiance with the Standard. |
704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to document a staff development program policy and procedure which included timeframes and procedures for each component of the the staff development program.
The findings included:
The onsite licensure renewal inspection was conducted June 26-28, 2012. The facility policy and procedure manual was reviewed on June 26, 2012. The policy and procedure failed to document the definition of the annual training year the procedures for the assessment, the overall training plan, feedback from staff for training completed and time frames for completion of each component and where it would be documented.
The findings were reviewed with the Facility Director and Clinical Supervisor and were not disputed.
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Plan of Correction
The Program Director shall update current policy relating to this Standard to include the following: (1) Program Director shall assess staff training needs via questionnaires completed by all staff by December 1 of each year and place a copy of such in the policy and procedure manual; (2) Program Director shall develop an overall plan for addressing these needs by December 15 of each year and place a copy of such in the policy and procedure manual; (3) The Program Director in collaboration with each clinician shall complete individual training plans by January 15 of each year and place copies of such in the policy and procedure manual and in personnel records; (4) A training evaluation form is to be completed by each clinician following each training and submitted to the program director with a copy of such placed in the personnel record; (5) The Program Director shall complete an annual evaluation of the overall training plan by December 31 of each year and submit a copy of such to the Executive Director with another copy placed in the policy and procedure manual. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on the review of the staff personnel and training records, the facility failed to ensure that each counselor received at least 25 hours of annual training for the 2011 training year for three of three personnel and training records for counselors.
The findings included:
Seventeen employee personnel and training records were reviewed during the onsite licensure renewal inspection conducted from June 26-28, 2012. Six personnel and training records were those of counseling staff. Three of these had been employed for the full training year and were required to include documentation that they had received 25 hours of training for the 2011 training year. Three of three counselors failed to obtain documentation that they had received 25 hours of training for the 2011 training year.
Employee # 10 was hired 9/4/10. This employee had 0 hours of training documented for the 2011 training year.
Employee # 12 was hired 2/1/10. This employee had 10 hours of training documented for the 2011 training year.
Employee # 13 was hired 3/6/08. This employee had 10 hours of documented training for the 2011 training year.
The findings were reviewed with the Facility Director and the Clinical Supervisor and were not disputed.
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Plan of Correction
Men and Women for Human Excellence shall ensure that each counselor receive at least 25 hours of annual training for the 2012 training year. The Program Director will review personnel files quarterly to assess progress staff is making towards achieving the goals on their annual training plans. A lack of progress shall necessitate a meeting between the clinician, clinical supervisor and program director in order to facilitate compliance with this Standard. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
A physical plant inspection was conducted on June 28, 2012. Two bathrooms, one at the 2603 address on the second floor and one at the 2600 address on the first floor, had exhaust fans in the bathrooms which were filled with dust and dirt. The bathroom at the 2603 address, second floor, had a badly rusted radiator next to the toilet.
The findings were reviewed with the Facility Director and the Clinical Supervisor and were not disputed.
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Plan of Correction
Men and Women for Human Excellence shall ensure that all Agency bathrooms are maintained in a functional, clean and sanitary manner at all times. The Maintenance crew chief (or designee) shall inspect and clean all bathrooms on days when the Agency is operational. Also, the Program Director (or designee) shall make weekly checks to ensure compliance with this Standard. Exhaust fans in all bathrooms have been thoroughly cleaned. Also, the radiator in the bathroom on the second floor at 2603 has been scraped, sanded, and repainted. |
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 the review of employee training records, the facility failed to ensure that each employee is trained in the use of fire extinguishers upon hire. No documentation was available to substantiate that this training occurred as required in four of four employee records.
The findings include:
Seventeen employee records were reviewed during the inspection conducted from June 26-28, 2012. Four of these were records were for support staff. Four of four records of support staff failed to include documentation that the employee had received the required fire extinguisher training upon hire.
Employee # 14 began employment at the facility on 3/12/12. No documentation that the employee had received training in the use of fire extinguishers was included in the employee training record as of June 28, 2012.
Employee # 15 began employment at the facility on 2/19/11. No documentation that the employee had received training in the use of fire extinguishers was included in the employee training record as of June 28, 2012.
Employee # 16 began employment at the facility on 9/30/11. No documentation that the employee had received training in the use of fire extinguishers was included in the employee training record as of June 28, 2012.
Employee # 117 began employment at the facility on 5/23/11. No documentation that the employee had received training in the use of fire extinguishers was included in the employee training record as of June 28, 2012.
The findings were reviewed with the Facility Director and the Clinical Supervisor and were not disputed.
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Plan of Correction
MWFHE shall ensure that each employee is trained in the use of fire extinguishers upon hire. The Program Director (or designee) shall provide such training. Documentation indicating that training has been completed shall be placed in the personnel files of each staff person. During monthly review of personnel files, the Office Manager (or designee) shall ensure that documentation of fire extinguisher training is in the records. On June 29, 2012 fire extinguisher training was provided to Employuees # 15. 16, and 17. |
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 the review of employee training records, the facility failed to ensure that each employee is trained in emergency procedures. No documentation was available to substantiate that this training occurred as required in four of four employee records.
The findings include:
Seventeen employee records were reviewed during the inspection conducted from June 26-28, 2012. Four of these were records were for support staff. Four of four records of support staff failed to include documentation that the employee had received the required emergency procedure training.
Employee # 14 began employment at the facility on 3/12/12. No documentation that the employee had received training in emergency procedures was included in the employee training record as of June 28, 2012.
Employee # 15 began employment at the facility on 2/19/11. No documentation that the employee had received training in emergency procedures was included in the employee training record as of June 28, 2012.
Employee # 16 began employment at the facility on 9/30/11. No documentation that the employee had received training in emergency procedures was included in the employee training record as of June 28, 2012.
Employee # 117 began employment at the facility on 5/23/11. No documentation that the employee had received training in emergency procedures was included in the employee training record as of June 28, 2012.
The findings were reviewed with the Facility Director and the Clinical Supervisor and were not disputed.
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Plan of Correction
MWFHE shall ensure that each employee is trained in emergency procedures upon hire. The Program Director (or designee) shall provide such training. Documentation indicating that training was completed shall be placed in the personnel files of each staff person. During monthly review of personnel files, the Office Manager (or designee) shall ensure that documentation of emergency procedures is in the records. On June 29, 2012 emergency procedure training was provided to Employees # 14, 15, 16, and 17.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of financial statements presented to Division staff, the facility failed to document an annual audit for the fiscal year ended 12/31/2010.
The findings included:
An onsite licensing renewal inspection was conducted from June 26-28, 2012. This is a carryover citation from the previous inspection. The approved plan of correction indicated that a 2010 audit would be documented by July 19, 2012. The 2011 audit should be completed by June 30, 2012 to maintain full compliance for the next licensing inspection.
The findings were discussed with the Project and Facility Directors on December 12, 2011 and were disputed
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Plan of Correction
Men and Women for Human Excellence (MWFHE) shall document an annual audit for the fiscal years ending 12/31/2010 and 12/31/2011. The Program Director shall obtain an opinion from the accountant that was retained by the agency to perform the 12/31/2010 audit so that it is complete and in full compliance with State standards. The Program Director shall meet with the President/CEO and Accountant to discuss and document procedures for completing timely annual audits according to state standards. Such procedures shall be reviewed quarterly to assure compliance and maintained in the policy and procedure manual. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on the review of the facility policy and procedure manual, the facility failed to document a procedure which complied with 4 Pa. Code subsection 255.5.
The findings included:
The facility manual was reviewed during the onsite licensing renewal inspection of June 26-28,2012. The written policy and procedure describing confidentiality failed to include documentation as to who is responsible for maintaining the confidentiality of the client records. The policy and procedure also omitted reference to 4 Pa. Code 255.5 (a) (1-10).
The policy manual included a Notice of Privacy Practices statement which did not comply with the stipulations of Act 63 of 1972 at 71 P.S. subsection 1690.108 (b) which states that Patient records "..may be disclosed only with the patient's consent..." or 42 CFR Part 2, Subpart A, subsection 2.2 (b)(1) regarding the requirement for disclosures with the prior written consent of the client.
The Notice of Privacy Practices includes a number of instances which would allow the program to release client identifying information without client consent and which conflict with the applicable laws and regulations cited previously.
Section 4a of the notice indicates that client information can be included in a facility directory without client consent.
Section 4b states that information may be released without client consent, in regard to notification "... to a relative, friend or individuals involved in your care, if permitted by relevant law and/or regulation. We will attempt to seek, or in some circumstances, using our professional judgement will infer your permission to make the disclosure."
Section 5e and k makes reference to duty to warn third parties without client consent which is not consistent with 42 CFR Part 2, Subpart E, subsection 2.63.
The findings were reviewed with the Clinical Supervisor and Facility Director and were not disputed. This is a repeat citation.
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Plan of Correction
Men and Women for Human Excellence shall ensure that a written procedure be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to: (1) Confidentiality of client identity and records. The Program Director shall revise current Agency policy and procedure relating to this standard to the extent that the Agency is in full compliance. Included in the revised policy shall be documentation relating to who is responsible for maintaining the confidentiality of the client records. Also included in the revised policy shall be reference to 4 Pa. Code 255.5 (a) (1-10) |
709.28(a)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(2) Staff access to client records.
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Observations
Based on the review of the facility policy and procedure manual, the facility failed to document a procedure detailing who may have access to client records and the method for gaining access.
The findings included:
The facility policy and procedure manual was reviewed during the inspection conducted from June 26-28, 2012. The facility manual did not contain documentation of a policy and procedure identifying project staff who may have access to client records and the methods by which staff gain access to the records.
The finding was reviewed with the Clinical Supervisor and the Facility Director and was not disputed.
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Plan of Correction
Men and Women for Human Excellence shall ensure that a documented procedure detailing who may have access to client records and the method for gaining access is in place. The Program Director shall revise current policy relating to this standard so that it identifies agency staff that may have access to client records and the methods by which staff gain access to the records. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document a medical history which included the family medical history in three of nine client records.
The findings included:
Eighteen client records were reviewed during the inspection conducted June 26-28, 2012.
Nine client records were due to include documentation of medical histories. Three of nine client records failed to include documentation of medical histories which included the family medical history.
Client record #3- The client was admitted on 4/19/12 and was last treated on 6/13/12. The medical history failed to include documentation of a family medical history.
Client record # 7- This client was admitted on 1/18/12 and was last treated on 6/12/12. The medical history failed to include documentation of a family medical history.
Client record # 11- This client was admitted on 4/9/12 and was last treated on 6/24/12. The medical history failed to include documentation of a family medical history.
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The findings were reviewed with the facility director and Clinical Supervisor and were not disputed.
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Plan of Correction
Men and Women for Human Excellence shall ensure, through continued staff development and bi-weekly auditing of client records, that a family medical history is documented in all client records. The Program Director and Clinical Supervisor shall monitor compliance with this standard. A family history has been completed and documented in client record # 3, 7, 11. Reviews of this standard shall take place during staff meetings, individual supervision and other onsite and offsite trainings |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of client records , the facility failed to document measurable, realistic treatment goals and objectives, based on the assessed needs of each client on each client treatment plan.
The findings included:
The onsite licensure renewal inspection was conducted June 26-28, 2012. 28 Pa. Code Chapter 709.92(a)(1). specifies that short and long term goals are to be documented for each client and that goals should be realistic and measurable. During the inspection 18 client records were reviewed. Eleven records were applicable for the requirement of having measurable , realistic short and long term goals documented. Seven of these records had goals which were not individualized to the client's needs. Goals on these records tended to be generic containing such goal statements as : " attend treatment sessions" ; "attend 5 NA meetings per week"; "submit weekly UDS with negative results" , etc.
Record # 1 This client was admitted on 5/16/12 and was last treated on 6/4/12. The stated goals and objectives, while measurable , were not individualized to the client based on the assessed needs. The goals were stated in generic terms.
Record #3- The client was admitted on 4/19/12 and last treated on 6/13/12. The stated goals and objectives, while measurable , were not individualized to the client based on the assessed needs. The goals were stated in generic terms.
Record # 6- The client was admitted on 5/24/12 and last treated on 6/27/12. The stated goals and objectives, while measurable , were not individualized to the client based on the assessed needs. The goals were stated in generic terms.
Record # 8- This client was admitted on 4/20/12 and last treated on 6/14/12. The stated goals and objectives, while measurable , were not individualized to the client based on the assessed needs. The goals were stated in generic terms.
Record # 10- This client was admitted on 5/2/12 and last treated on 6/1/12. The stated goals and objectives, while measurable , were not individualized to the client based on the assessed needs. The goals were stated in generic terms.
Record # 11- This client was admitted on 4/9/12 and last treated on 6/24/12. The stated goals and objectives, while measurable , were not individualized to the client based on the assessed needs. The goals were stated in generic terms.
Record # 13- This client was admitted on 4/9/12 and last treated on 6/11/12. The stated goals and objectives, while measurable , were not individualized to the client based on the assessed needs. The goals were stated in generic terms.
The findings were reviewed with the facility director and Clinical Supervisor and were not disputed.
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Plan of Correction
Men and Women for Human Excellence shall ensure, through continued staff development and bi-weekly auditing of client records, that measurable and realistic treatment goals and objectives based on the assessed needs of each client are documented and placed in each client's record. The Program Director and Clinical Supervisor shall monitor compliance with this standard with reviews of the standard taking place during staff meetings, individual supervision and other onsite and offsite trainings |
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.
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Observations
Based on the review of client records and the facility policy and procedure manual, the facility failed to document case consultations as required by facility policy in 18 of 18 client records and failed to include a quarterly case consultation in one of one client records.
The findings included:
Eighteen client records were reviewed during the onsite licensure renewal inspection conducted from June 26-28, 2012. Written facility policy specifies that case consultations are to be conducted within two weeks after admission for each client and within two weeks prior to discharge for each client. Eleven client records failed to include documentation of case consultations within the timeframes specified in facility policy and procedure. One client record was required to have a quarterly case consultation and failed to include documentation of the consultation.
Client record # 1 - This client was admitted on 5/16/12 and was last treated on 6/4/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy.
Client record # 2 This client was admitted on 5/31/12 and was last treated on 6/13/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy.
Client record #3- The client was admitted on 4/19/12 and last treated on 6/13/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy.
Client record # 4 This client was admitted on 5/31/12 and was last treated on 6/1/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy.
Client record # 5 This client was admitted on 6/6/12 and was last treated on 6/8/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy.
Client record # 6- The client was admitted on 5/24/12 and last treated on 6/27/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy.
Client record # 7- This client was admitted on 1/18/12 and was last treated on 6/12/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy. No quarterly case consultation was documented for this client.
Client record # 8- This client was admitted on 4/20/12 and last treated on 6/14/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy.
Client record # 9 This client was admitted on 4/26/12 and was last treated on 6/18/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy.
Client record # 10- This client was admitted on 5/2/12 and last treated on 6/1/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy.
Client record # 11- This client was admitted on 4/9/12 and last treated on 6/24/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy.
Client record # 12 This client was admitted on 5/16/12 and was last treated on 6/4/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy.
Client record # 13- This client was admitted on 4/9/12 and last treated on 6/11/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy.
Client record # 14- This client was admitted on 4/5/12 and last treated on 6/11/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy.
Client record # 15- This client was admitted on 4/6/12 and last treated on 6/12/12. There was no documentation of a case consultation within two weeks of admission as required by written facility policy.
The findings were reviewed with the facility director and Clinical Supervisor and were not disputed. This is a repeat citation.
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Plan of Correction
Men and Women for human Excellence has developed an updated policy relating to case consultations. The Program Director and Clinical Supervisor has met with all clinical staff to review and discuss implementation of the new policy and procedure. Ongoing review of the policy will continue taking place during staff meetings and individual supervision. Compliance shall be determined via bi-weekly audits of clients's records. |
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 during the licensure renewal inspection, compliance with this regulation could not be determined because there were no client records that were due to include documentation of aftercare planning. Confirmation of compliance will be determined during future on site licensing inspections. The original deficiency is listed below:
Based on the review of the facility policy and procedure manual and client records, the facility failed to document aftercare goals which included time frames for completion in two of two client records.
The findings included:
During the onsite licensing renewal inspection conducted December 12-14, 2011, twenty six client records were reviewed. Two client records were those of successfully discharged clients. Two of two client records reviewed failed to include documentation of timeframes for the completion of goals identified in the aftercare plan.
Client record # 20- This client was admitted on 8/3/09 and discharged on 7/5/11. The goals on the aftercare plan did not contain timeframes for completion.
Record # 21- This client was admitted on 8/19/10 and discharged on 9/29/11. The goals on the aftercare plan did not contain timeframes for completion.
The findings were reviewed with the Facility and Project Directors and were not disputed.
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Plan of Correction
The Facility and Clinical Director with all clinical staff present conducted documentation training. Clinical staff was instructed on the appropriate documentation of aftercare goals which include time frames for completion of goals identified in the aftercare plan. The Program Director and Clinical Director will conduct ongoing monthly documentation trainings to reinforce information. |