INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 3, 2013 to June 5, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Men & Women For Human Excellence, Inc. 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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709.22(b) LICENSURE Governing Body
709.22. Governing body.
(b) If a project is publicly funded, not more than one staff member of the project may sit on the governing body at a designated time.
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Observations
Based on a review of the current list of the facility's of Board of Directors that was issued January 2013, the facility failed to not have more than one staff member of the project on the governing body at a designated time.
The findings include:
The list of the facility's Board of Directors that was presented by the facility and reviewed on June 3, 2013 included the Chief Executive Officer and the Executive Director of the project as members of the Board of Directors.
The findings were confirmed during an interview with the project director on June 4, 2013 at approximately 9:30 A.M.
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Plan of Correction
The name of the Executive Director (staff member of Men & Women for Human Excellence) has been removed from the Board of Directors in order to be in compliance with this Standard. The President/CEO and the Executive Director shall monitor the Governing body quarterly to ensure ongoing compliance with this standard. Also, prior to adding a new Board of Director member, this standard shall be reviewed thoroughly. |
709.22(e)(3) 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:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the administrative material, the facility failed to make available to the public an annual report that included a statement disclosing the names of officers, directors and principal shareholders.
The findings include:
The administrative material was reviewed from June 3, 2013 to June 4, 2013. The document presented at the time of review as the annual report for the facility's January 1, 2012 to December 31, 2012 calendar year did not include a statement disclosing the names of officers, directors and principal shareholders.
The findings were confirmed during an interview with the project director on June 4, 2013 at approximately 9:30 A.M.
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Plan of Correction
Men & Women for Human Excellence shall make available to the public an annual report that includes a statement disclosing the names of officers, directors and principal shareholders. The Executive shall be responsible for monitoring this standard to ensure that the Agency remains in full compliance with it. With respect to the current annual report, it shall be edited to include names of officers, directors and principal shareholders and then republished. A copy of said report shall be available to the public and for future onsite inspections |
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 an interview with the project director, the facility failed to provide an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility was required to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of their fiscal year. The facility's 2011 to 2012 fiscal year ended on June 30, 2012. On June 3, 2013 and June 4, 2013, the Licensing Specialist asked to see a copy of the facility's annual audit of financial activities associated with the project's drug/alcohol abuse services for the facility's 2011 through 2012 fiscal year. An annual audit of financial activities associated with the project's drug/alcohol abuse services for the facility's 2011 through 2012 fiscal year was not presented for review.
The findings were confirmed during an interview with the project director on June 4, 2013 at approximately 9:30 A.M.
This is a repeat citation. The facility was cited on June 28, 2012; April 20, 2012; and December 14, 2011 for noncompliance with this standard.
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Plan of Correction
Men & Women for Human Excellence has obtained the services of an independent public accountant to complete an annual audit of financial activities associated with the project's drug/alcohol abuse services for the fiscal year of 2012. The Executive Director shall be responsible for monitoring the progress of the audit and ensuring its timely submission and availability for onsite inspection as well as ensuring the ongoing compliance of this standard with respect to future audits. Also with respect to the current deficiency, the audit for the fiscal year of 2012 shall be completed by September 19, 2013 |
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 a review of the facility's policy and procedure manual, the facility failed to provide a written procedure that comply with 4 Pa. Code 255.5 (relating to project and coordinating bodies: disclosure of client-oriented information) regarding confidentiality of maintenance and security of the records.
The findings include:
From June 3, 2013 to June 4, 2013, the facility's policies and procedures on confidentiality were reviewed. The facility's policies and procedures on confidentiality did not include documentation of the person responsible for the maintenance and security of the client records.
The findings were confirmed during an interview with the project director on June 5, 2013 at approximately 1:00 P.M.
This is a repeat citation. The facility was cited on June 28, 2012 and April 20, 2012 for noncompliance with this standard.
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Plan of Correction
The Executive Director shall be responsible for ensuring that the facility's policies and procedures on confidentiality include documentation of the person(s) responsible for the maintenance and security of the client records. With respect to this specific standard, Men and Women for Human Excellence's policy on confidentiality have been revised to include the person responsible for the maintenance and security of the client records. The revised policy shall be presented to the board of directors at the next scheduled board meeting (September 2013)for review and approval. |
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 a review of the facility's policy and procedure manual, the facility failed to provide a written procedure that comply with 4 Pa. Code 255.5 (relating to project and coordinating bodies: disclosure of client-oriented information) regarding staff access to client records.
The findings include:
From June 3, 2013 to June 4, 2013, the facility's policies and procedures on confidentiality were reviewed. The facility's policies and procedures on confidentiality did not include documentation of the project staff who has access to the client records.
The findings were confirmed during an interview with the project director on June 5, 2013 at approximately 1:00 P.M.
This is a repeat citation. The facility was cited on June 28, 2012 for noncompliance with this standard.
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Plan of Correction
The Executive Director shall be responsible for ensuring that the facility's policies and procedures on confidentiality include documentation of the project's staff that shall have access to the client records. With respect to this specific standard, Men and Women for Human Excellence's policy on confidentiality have been revised to include documentation of the agency staff that has access to the client records.
The Executive Director is to complete changes in the agency's policy by July 17, 2013 and present such change to the board of directors at the next scheduled board meeting (September 2013) for review and approval.
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on observations on June 4, 2013, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit.
The findings include:
A physical plant inspection was conducted on June 4, 2013. On June 4, 2013, four unisex public restrooms were inspected. From approximately 10:22 A.M. to 10:43 A.M., the following were observed.
1) The sink in the unisex public restroom located at the facility's 2600 W. Cecil B. Moore Avenue location in group room b had a hot water temperature reading of 125 Fahrenheit.
2) The sink in the unisex public restroom located at the facility's 2600 W. Cecil B. Moore Avenue location in the rear of the of the main hallway had a hot water temperature reading of 150 Fahrenheit.
3) The sink in the unisex public restroom located at the facility's 2603 W. Cecil B. Moore Avenue location on the first floor had a hot water temperature reading of 125 Fahrenheit.
4) The sink in the unisex public restroom located at the facility's 2603 W. Cecil B. Moore Avenue location on the second floor had a hot water temperature reading of 125 Fahrenheit.
The findings were confirmed during an interview with the project director on June 4, 2013 at approximately 10:44 A.M.
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Plan of Correction
The temperature of the hot water in all bathrooms of the agency shall not exceed 120 degrees Fahrenheit. The maintenance chief shall be responsible for monitoring the temperature of the hot water. With respect to this standard, the temperature level for the hot water in the bathrooms cited has been adjusted to be in compliance with the standard. The maintenance chief is to do a weekly check to ensure that the water temperature does not exceed 120 degrees Fahrenheit. |
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 observations on June 4, 2013, 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 4, 2013. It was observed at approximately 10:22 A.M., that the exhaust fan in the unisex public restroom located at the facility's 2600 W. Cecil B. Moore Avenue location in the rear of the of the main hallway was filled with dust and dirt. It was also observed at approximately 10:43 A.M., that the exhaust fan in the public restroom located at the facility's 2603 W. Cecil B. Moore Avenue location on the second floor was filled with dust and dirt.
The findings were confirmed during an interview with the project director on June 4, 2013 at approximately 10:44 A.M.
This is a repeat citation. The facility was cited on June 28, 2012 for noncompliance with this standard.
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Plan of Correction
The maintenance crew chief shall ensure that each bathroom is in functional, clean and sanitary manner at all times. To accomplish this, the maintenance crew chief/or designee shall clean or have cleaned all bathrooms on a daily basis. Included in the cleaning of the bathrooms shall be the exhaust fan in the unisex public restroom located at the facility's 2600 W. Cecil B. Moore Avenue location in the rear of the main hallway and the exhaust fan in the public restroom located at the facility's 2603 W. Cecil B. Moore Avenue location on the second floor. Exhaust fans are to be cleaned on the outside (the plate) as well as on the inside (exhaust duct). With respect to this specific citation, the above process has been completed |
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 a review of client records, the facility failed to document a case consultation in four of eleven client records reviewed.
The findings include:
The facility's policy titled: "G. Case Consultation (Reviews)," states:
"All active cases will be reviewed at a minimum of ever ninety (90) days if the client was admitted to the program."
From June 4, 2013 to June 5, 2013, eleven client records requiring documentation of a case consultation were reviewed. The facility did not document a case consultation in four of eleven records reviewed, specifically, client records # 3, 6, 9, and 11.
Client # 3 was admitted January 23, 2013. A case consultation was due April 19, 2013. However, client record # 3 did not include documentation of a case consultation as of June 5, 2013.
Client # 6 was admitted January 22, 2013. A case consultation was due April 18, 2013. However, client record # 6 did not include documentation of a case consultation as of June 5, 2013.
Client # 9 was admitted November 29, 2012. A case consultation was due February 27, 2013. However, client record # 9 did not include documentation of a case consultation as of June 5, 2013.
Client # 11 was admitted January 18, 2013 and discharged May 2, 2013. A case consultation was due April 18, 2013. However, client record # 11 did not include documentation of a case consultation as of June 5, 2013.
The findings were confirmed during an interview with the project director on June 5, 2013 at approximately 3:30 P.M.
This is a repeat citation. The facility was cited on June 28, 2012; April 20, 2012; and December 14, 2011 for noncompliance with this standard.
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Plan of Correction
The Clinical Supervisor reviewed with all clinical staff agency's policy and state standards relating to this citation. Also, the Quality Assurance person (QA) has been informed by the clinical supervisor to note any and all deficiencies relating to the omission of timely case consultations. The QA person is to review client records on a bi-weekly basis and report all non-compliance of this standard to the clinical supervision who shall meet with the primary clinician for supervision and to inform the clinician that he/she has 72 hours in which to document and chart the missing consultation. With respect to this specific citation, case consultations have been completed for client #3, client #6, and client #9 and placed in their respective charts. A case consultation could not be completed on Client #11 because that person was discharged on May 2, 2013. |
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 a review of client records, the facility failed to document follow-up information or follow-up information in accordance with their policy and procedures in five of six client records reviewed.
The findings include:
The facility's policy titled: "M. Referral/Follow-up," states:
"The primary counselor with written consent should within one week of when the referral is to be completed, contact the referral source by phone to determine the disposition of the referral. At the minimum one reasonable attempt should be made by phone or with a follow-up letter to the referral source, documented in the client's file to include a copy of the letter........All clients who successfully complete the program will be followed-up on, or about 30, 60 and 90 days from the date of discharge either through a Follow-up Session, Phone Contact, or via client and/or Family Follow-up Evaluation."
From June 4, 2013 to June 5, 2013, six client records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information or document follow-up information according to their policy and procedures in five of six records reviewed, specifically, client records # 11, 12, 13, 14, and 15.
Client # 11 was admitted January 18, 2013 and was discharged May 2, 2013. The follow-up information was due June 1, 2013. However, client record # 11 did not include documentation of follow-up information as of June 5, 2013.
Client # 12 was admitted January 11, 2013 and was discharged April 15, 2013. The follow-up information was due April 22, 2013. However, the follow-up information was not completed until May 15, 2013.
Client # 13 was admitted June 16, 2011 and was discharged March 21, 2013. The follow-up information was due April 20, 2013. However, client record # 13 did not include documentation of follow-up information as of June 5, 2013.
Client # 14 was admitted June 23, 2011 and was discharged March 21, 2013. The follow-up information was due April 20, 2013. However, client record # 14 did not include documentation of follow-up information as of June 5, 2013.
Client # 15 was admitted December 18, 2010 and was discharged March 13, 2013. The follow-up information was due April 12, 2013. However, client record # 15 did not include documentation of follow-up information as of June 5, 2013.
The findings were confirmed during an interview with the project director on June 5, 2013 at approximately 3:30 P.M.
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Plan of Correction
The Clinical Supervisor reviewed, with all clinical staff present, agency's policy and State standards relating to this citation. Also, the Quality Assurance person (QA) has been informed to note any and all deficiencies relating to the omission of timely discharge follow-ups. The QA person or designee shall review on a bi-weekly basis the records of all clients who were discharged during the 90 days prior to the bi-weekly review of closed records and report all non-compliance of this standard to the clinical supervisor who shall meet with persons responsible for monitoring timely follow-ups to discuss this standard and ensure that such follow-ups takes place as required. With respect to this specific citation, follow-up have now been completed by the clinical supervisor/designee for client 11, 12, 13, 14, and 15. |
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 a review of personnel records, the facility failed to ensure that clinical supervisors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision in one of one personnel record reviewed.
The findings include:
From June 3, 2013 to June 4, 2013, one personnel record was reviewed for documentation that a core curriculum in clinical supervision was completed for a clinical supervisor who has not functioned for 2 years as a supervisor in the provision of clinical services. The facility failed to ensure that the clinical supervisor completed a core curriculum in clinical supervision in one of one personnel record reviewed, specifically, personnel record # 2.
Employee # 2 is the clinical supervisor and was hired November 26, 2012. Based on employee # 2's resume, she does not have experience functioning as a supervisor in the provision of clinical services. Personnel record # 2 did not include documentation that employee # 2 completed a core curriculum in clinical supervision as of June 4, 2013.
The findings were confirmed during an interview with the project director on June 4, 2013 at approximately 9:30 A.M.
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Plan of Correction
The Executive Director shall ensure that clinical supervisors who have not functioned for 2 years as supervisors in the provision of clinical services complete a core curriculum in clinical supervision prior to the start of employment. With respect to this citation, the clinical supervisor shall complete a core curriculum in clinical supervision by September 19, 2013. The Program Director shall follow-up to ensure that the training/curriculum is completed. |