INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 1 through 2, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on August 28, 2006.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Employee #4 does not meet the requirements for the position of counselor.
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Plan of Correction
Upon review of hiring clinical staff for MWFHE, outpatient treatment program all applicants will submit a resume, credentials along with two references that verify their credentials and qualifications. The Clinical Director will make telephone calls to verify the information. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
There is currently no CPR or first aid coverage for the project's hours of operation.
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Plan of Correction
MWFHE, Inc. have sent up CPR and first aid trainings for all of its clinical staff members. During the month the Clinical Dirctor, Administrative Assistance and clinical staff will be scheduled and attend CPR and First Aid trainings. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Employee #1 did not receive the required training hours for the training year reviewed.
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Plan of Correction
Executive Director will be responsible for ensuring that all clinical staff has the required training hours. Each direct service staff member will receive a yearly training schedule that will include twenty-five (25) hours, and management level employees will receive a training schedule that will include tweleve (12) training hours. |
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
Employee #3 did not receive the 25 training hours required for the last training year.
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Plan of Correction
The Clinical Director will insure that all clinical staff follow and complete the yearly training schedule that has been provide my the Executive Director. |
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
There is no documentation of staff receiving fire extinguisher training.
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Plan of Correction
As stated in MWFHE, Inc. Policy and Procedure manual after each staff member have been familiarize and trained with the agency's fire emergency and evacuation plan he/she will sign proof of their understanding of the trainng and their understaning of their responsiblties. |
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
The program did not conduct fire drills for the months of May through September 2005.
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Plan of Correction
Men & Women For Human Excellence Inc. continues to conduct unannounce fire drills at least one per month. Proper documention will continue to be keep in MWFHE, Inc. fire drill log. |
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
There is no documentation of staff receiving emergency training.
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Plan of Correction
As stated in MWFHE, Inc. Policy and Procedure Manual, each staff member will trained on the correct procedure for emergencys. Upon the completion of the staff member trainning the individual will sign documentation the he/she understand and have compeleted their training. |
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
An annual report has not been completed.
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Plan of Correction
President/CEO of MWFHE, Inc. will submit in the news letter to the community each year a annual report of all MWFHE, Inc. operations for the year. |
709.26(b)(4) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(4) The implementation of Federal, State and local statutes concerning fair employment practices.
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Observations
There were no indicators of compliance for the implementation of Federal, State and local statutes concerning fair employment practices.
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Plan of Correction
THe Clinical Director will meet with all new employees of MWFHE, Inc. to discuss all federal, State and Local fair employment practices. The clinical Director will have the employee sign and date documention of the meeting. MWFHE, Inc. will also post thoughout its facilty posters of compliance to the fair employment practices by the Federal, State and Local agenies. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Reference results were missing in five of six employee records reviewed, #1, 2, 4, 5 and 6.
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Plan of Correction
MWFHE, Inc. has implemeneted in its employee manual that all new hires must summit three (3) verbal references and two(2) written references before begining employment. The Clinical Director during the interview process will be responbsible for ensuring that new employees references are valid by fellowing up on references. |
709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
There was no salary information documented in employee records.
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Plan of Correction
The Clinical Director will meet with each new employee and review his/hers salary. Upon acceptance of his/hers salary the staff person will sign and date documents of their acceptance. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Performance evaluations have not been completed according to program policy.
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Plan of Correction
The Clinical Director will conduct an evaulation of each clinical staff person on a yearly basis. During the yearly review of the evaluation the Clinical Director and staff person will meet to review their evaluation. The staff person will date and sign their acceptance or non-acceptance of their evaluation. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
A general authorization form signed by clients was in client records that did not specify who the information was being released to, the specific information to be released or the purpose of the consent. In addition, the clients are asked to sign a consent form which states that no information will be released without a client's written consent, failing to inform them of the exceptions allowed by state and federal confidentiality laws. These are not informed and voluntary consents.
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Plan of Correction
The Clinical Director will check all new admission chart within 48 hours of admissions to assure that release information is accurate. Clinical Director will also conduct an internal audit bi-weekly of each therapist's chart to ensure that the authorizations include the names and phone numbers of person's or entities that the release of information is specifically garnered towards. Updated authorizations also include the exception clause that states the times an agency may not need an informed or voluntary consent to release information based off exceptions allowed by state and federal confidentiality laws.
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709.30(1) LICENSURE Client Rights
709.30. Client rights.
(1) A person receiving care or treatment under section 7 of the act (71 P. S. 1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
This client right is not documented in the policy and procedure manual, nor on the client rights form signed by the client at the time of admission.
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Plan of Correction
MWFHE, Inc. has added to its policy and procedure manual a policy for client's rights. The policy was added as of 9/1/2006. |
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
The personal history was missing in client record #1. The educational and family history was missing information in client records #2, 3, 5 and 6. The employment information was unclear in client records #5 and 6. The recreational history was missing or limited in client records #3, 5 and 6.
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Plan of Correction
The Executive Director met with all clinical personnel and emphasized the importance of the bio-psychosocial assessment being completed concisely, section-by-section. The bio-psychosocial was also revised to make it a more precise and in depth assessment. The Clinical Director will be responsible for the monitoring of on-going records. |
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
The psychosocial evaluation was missing in client record #1. The psychosocial evaluations were a repeat of the historical data and client reported data rather than the counselor's assessment of the data in four of five client records reviewed, #2, 4, 5 and 6.
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Plan of Correction
The Clinical Director will be responsible for training and monitoring staff record for on-going compliance. The clinical evaluation has been revised. A clinical narrative will be completed based off the clinician's observation and assessment of what he/she depicts is happening during the assessment. Non-verbal cues will be monitored more closely as well as the vagueness of information given by the client. The clinician will be responsible for asking more open ended questions as well as doing more probing to get more than a generalized response from the client. |
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.
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Observations
Proposed support systems were not included on the treatment plan in three of three client records reviewed, #4, 5 and 6.
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Plan of Correction
The Clinical Director will be responsible for training and monitoring staff records for ongoing compliance. Support systems such as 12-step meetings, religious groups (if affiliated) and spiritual groups will be added as part of the treatment plan for all clients who are building a support network as a part of their treatment plan; attending such meetings would be implemented as the action steps section in the treatment plan. |
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
Treatment plan updates were missing in one of three client records, #2. Treatment plan updates were more than a week late in client record #5. The updates completed did not discuss the progress of all prior treatment goals and objectives, or the resolution or reasoning for the formation of new goals in two of three client records, #4 and 5.
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Plan of Correction
The Clinical Director will be responsible for training and monitor staff records for ongoing compliance. MWFHE, Inc. have implemented a plan to do treatment plans for clients at least two (2) weeks before the due date to insure that the treatment plan is done prior to the expiration date. This proces will help with clients who are no-shows, absent or drop out at the time their individual treatment plan is due. The clinical Director will make sure that the treatment plan includes a reflection of the previous treatment plan as well as receive a verbal clinical reason from clinician as to why a new goal is being implemented before signing off on the treatment plan. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Medication information was not documented in one of two client records reviewed, #5.
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Plan of Correction
MWFHE, Inc. Clinical Supervisor will proform monthly audits on clients charts to ensure that proper information is being obtain and recorded. |
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
Case consultations were missing in three of three client records reviewed, #2, 4 and 5.
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Plan of Correction
MWFHE, Inc. have implemented a procedure will case consultations will be conducted on all client every sixty (60) days. The Clinical Director will monitor compliance in this area during clinician's supervision. |
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
An aftercare plan was missing in one of one record reviewed, #1.
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Plan of Correction
All clients are to have an after care plan weather the client successfully or unsuccessfully discharge from treatment. MWFHE, Inc. Clinical Supervisor will review all clients charts to ensure that all proper documentation is recorded. |
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
Discharge summaries did not include the reasons for treatment or services offered in two of two client records reviewed, #1 and 2. The response to treatment and client status were missing or incomplete in two of two client records reviewed, #1 and 2.
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Plan of Correction
The Clinical Director will be responsible for training and monitoring of records for ongoing compliance. MWFHE, Inc. has revised the discharge summary to include client's treatment history, which entails reason for treatment, services offered, treatment compliance and prognosis. |
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
Follow up information was not documented in two of two client records reviewed, #1 and 3.
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Plan of Correction
The Clinical Director will be responsible for training and monitoring records for ongoing compliance. MWFHE, Inc. will ensure that all clients are followed up with despite the state of their discharge (compliant or non-compliant). After discharge follow ups are preformed on a 30, 60 and 90 day period. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
The follow up policy was limited to those who successfully completed treatment and did not include follow up for the other types of discharged clients.
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Plan of Correction
MWFHE, Inc. Drug and Alcohol Manual page 113,2a "Clients successfully, administratively, voluntarily or involuntarily discharge from treatment will be followed up by the client's primary counselor. 2b "These clients will be followed-up on or before 30, 60 and 90 days from the date of discharge either through a follow-up session, phone contact, mail,via client or family. The agency will ensure that all clients are followed up with despite the state of discharge (compliance or non-compliance). If the client is referred to another level care or facilty, the same procedure will be adhered to and monitored by Clinical Director. Primary counselor will follow-up within 7 days of appointment with new treatment provider provider. |