INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 2 and 3, 2007 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 April 25, 2007.
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Plan of Correction
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Documentation did not support that the counselor assistant, staff #5, is supervised by a full time counselor or clinical supervisor.
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Plan of Correction
The Clinical Director/Supervisor will directly meet and provide supervision to the Counselor Assistant for a minimum of ninety minutes per week. Each session will be recorded and/or documented and placed in the Counselor Assistant's permanent record.
This process will last for a period of at least nine months. During this time, the Clinical Director/Supervisor will also co-facilitate both individual and group sessions with the Counselor Assistant. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Staff #5 did not have documentation that a semiannual performance evaluation was completed.
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Plan of Correction
MWFHE, Inc. Clinical Director will ensure that the Clinical Supervisor provides a semi-annual performance evaluation on the Counselor Assistant. The initial evaluation will be performed six months from hiring date. The counsleor assistants next evaluation will be six month after the initial. All evaluation will be completed within thirty of due date. |
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
No documentation was provided of the assessment of staff training needs.
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Plan of Correction
The Clinical Director will develop a training plan each year to meet the clinical and non-clinical needs of MWFHE, Inc. staff. The training needs of MWFHE Inc. outatient program will be developed based on growth of the agency, staff proformace and agency goals. At the begining of each calander year the Clinical Director will evaluate the training plan from ther pervious year and develop an training plan for the agency for the upcoming year. The training plan addressing staff needs will be completed witin thiry days of the calander year. This training plan will be documment and placed in MWFHE, INc. policies and procedure manual. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
The project did not present documentation that an overall plan was developed as part of the staff development program.
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Plan of Correction
At the beginning of each calendar year, the Clinical Director will review the stages of staff development from the previous year, if an area or deficiency did not meet the agecny's goals than the Clinical Director will address the area with the staff and add this deficiency to the agecny's upcoming year overall training plan for the direction of the staff training for the current year. During the current year MWFHE will be set up training to address the current needs of its staff. Training will be available for staff to attend by June 4, 2007. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
The annual evaluation of the training year 2006 was completed beyond the time frame identified in the policy and procedure.
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Plan of Correction
The Clinical Director will adhere to the time frame for submission of the annual evaluation as stated in the Men and Women for Human Excellence policy and procedure manual. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
There was no documentation to support the employees had any input into developing the individual training plans.
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Plan of Correction
The Clinical Director/Supervisor will meet with each staff person individually to discuss their concerns and issues with regards to their individualized training plan. This meeting will be documented and placed in each staff person's record. |
704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Individual training plans were identical for the counseling staff #2, 3, 4, 6, 7, despite differences in education, performance and experience.
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Plan of Correction
The Clinical Director/Supervisor will develop individualized training plans for each staff person based on duties, educational background, their needs and perfomance. The individualized training plan will be developed and evaulated once per year in order to review if any changes or additional trainings may be requried or needed. A copy of this training plan will be given to the staff person and a copy will be placed in their permanent records. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Staff #1 was missing documentation of having completed the Department approved HIV and TB/STD training hours. These training hours were to have been completed by June 2006. Staff #5 did not provide documentation of having received six hours of Department approved HIV training, due by January 2007.
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Plan of Correction
The Clinical Director will review all staff required training on a quarterly period to ensure that all stafff have begun the process of meeting their yearly required training hours. The Clinical Director will also meet with each staff member to review and inform the staff of training hours that are still needed and required by the Department of Health Drug and Alcohol Licensing program within the upcoming year. The Clinical Director have begin reviewing all staff taining hours to ensure that staff members have began to meet required training hours for current year. This process will be completed by June 4, 2007. |
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 insufficient coverage for all hours of operation. Only one staff person had documentation of first aid training which is insufficient to cover both shifts. Two staff had documentation of CPR training, one expires April 2007 and the other had expired in March 2007. This also insufficient staff coverage as it does not provide coverage when anyone is on leave or absent from the facility.
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Plan of Correction
The Clinical Director of MWFHE, Inc. outpatient treatment program will review on a yearly basic all staff training requriements to ensure that MWFHE, INc. have enought satff members with the required hours of trainings for CPR training. This process will ensure that all shifts will be covered with at least one staff person that has the required CPR and First Aid training as mandated by Department of Health Licensure. |
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
The project/facility director did not demonstrate that the required training hours for the training year reviewed had been obtained.
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Plan of Correction
MWFHE, INc. Executive Director will monitor the training hours of the Project/Facility Director, Clinical/Supervisor Director on a quartely basic (3 months) to snsure that the above name administrative staff are within the State of Pa. Division of Drug and Alcohol Programs yearly requirment hours for yearly trainings. Trainings requirements for staff will be completeted every clanader year. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
There were no signs for the second exit on the second and third floors.
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Plan of Correction
Exit signs were placed in clear veiw over the doorways on the second floor leading to the fire escape route. The same procedure was done on the third floor. |
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, due by June 30, 2006, has not been completed for the year 2005.
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Plan of Correction
MWFHE, Inc. President/CEO will be responsible for esuring that the agency provides an annual report from the previous year. This report will be available at the corporate office as of April of the following year. A annual report for 2006 will be available at MWFHE corp office as of May 4, 2007. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
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Observations
The project has not obtained written letters of agreement with primary referral sources.
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Plan of Correction
MWFHE, Inc. Administrative Assistant will be responsible for obtain letters of agreement with the primary referral sources that are in collaboration MWFHE, Inc. Also the Administrative Assistant will review the agency's referral soruces every six month to ensure that MWFHE, Inc. have updated its referral source list. MWHE, Inc. current referral list will be updated by July, 2007. |
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
The program has completed an analysis of the workforce to determine compliance with fair employment practices. The current policy states there are less than four employees, therefore this is N/A. There are actually at least nine employees.
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Plan of Correction
MWFHE, Inc. Execuive Director will be responsible for ensuring that MWFHE, INc. affirmative action plan is updated and reviewed each year. Furthermore the Executive Director will create a agency grid to illustrate areas and demonstrate the compliance of all area requirements. The grid will show a breakdown of areas such as sex, gender, age, education and ethnic background. This corretion will be complete by July 2007. |
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
Two of two staff required to have performance evaluations have not been evaluated. Staff #1 and 5 have not had the required performance evaluations according to program policy.
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Plan of Correction
MWFHE, Inc. Broad of Directors will conduct an yearly/annual performance evaluation on the Project Director. The Clinical/Supervisor Director will conduct an yearly performance evaluation on the Counselor Assistant. The Counselor Assistant will have an performance evaluation completed by June 4, 2007 |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
There is no documentation to demonstrate employees were made aware of their rights.
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Plan of Correction
The Clinical Director/Supervisor will meet with each new employee at the time of their hire to review staff rights. Each new staff memebr will sign and date form. A copy will be placed in their permanent record. All employees who are currently employed by MWFHE, Inc. outpatient treatment program will meet with the the Clinical Director/Supervisor to review their staff rights and sign and date form. All current employees with have staff rights reviewed by themselves and Clinical Director by June 4, 2007. |
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
Client record #1 contained documentation that information was released for transportation funding without obtaining a written consent from the client for said disclosure.
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Plan of Correction
The Clinical Director/Supervisor will ensure that MWFHE, INc. release forms pertaining to client's information are updated to excetly address the information that the client is releasing. The Clinical Director/Supervisor wil review client's records on a monthly basic to ensure that release form are completed correctly. All information that is to be released pertaining to clients, will have a written release of information stated the reason for the relase,what is to be release, length of time. MWFHE will provide in house trainings at least once a year to ensure that all staff are trained correctly. Updated release forms will be completed by May 28, 2007 |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
The purpose of the release of information was preprinted as "continuation of care" for all consents in the client records reviewed regardless of who the information was being released to. The purpose needs to ne specific to the consent.
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Plan of Correction
MWFHE, Inc Clinical Director/Supervisor will be responsible for ensuring that "Consent to Release" forms pertaining to client's will be updated by June 4, 2007. The updated form will illustrate specifically what the information is related too. i.e. housing, funding or treatment. The Clinical Director will review all forms relating to client release information yearly to ensure that forms are updated. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
The current data collection system did not allow efficient retrieval of the data needed to measure the project's performance during the licensing visit. The data system should identify the active drug and alcohol clients by counselor and dates of admission. The current system mixed mental health and discharged drug ans alcohol clients in with the active drug and alcohol clients. The discharged client data should include dates of admission and discharge and type of discharge and be able to separate clients by treatment type.
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Plan of Correction
MWFHE, Inc. data system has been updated to identify only drug and alcohol clients that may be active or inactive. This system also provides admission and discharge dates. |
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
Evaluations were missing in two of seven records reviewed, #5 and 8. In five of five client records, # 2, 3, 6, 7 and 9, the documentation was a repetition of the history and did not address clients problems/needs, support systems, coping mechanisms or clients attitude towards treatment.
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Plan of Correction
The Clinical Director/Supervisor will review clients charts that may have deficienices pertaining to psychosocial evaluations, upon review the clinical director/supervisor will meet with counselor to address any deficienices for corrections. Furthermore the Clinical Director/ Supervisor will review all clinical notes and forms to ensure that counselors provide clear and clinical documentation on all client's. MWFHE will provide in-house and outside trainings for clinical staff concerning the deveolpment of psychosocial evaluations. These trainings will be in place by June 4, 2007. |
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
The action steps were generalized, global, not measurable and not supportive of the corresponding goal statements in four of six records reviewed, # 2, 3, 7, 9.
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Plan of Correction
The CLinical Director/Supervisor will review client's records for deficienies in the area of treatment planning, if any deficienies are found the Clinical Director/Supervisor will meet with the counslor to make correction immediately. THe Clinical Diretor/Supervisor will ensure that any deficiencies found will be corrected by the counselor by June 4, 2007. MWFHE, Inc. will provide trainings both in-house and outside to address treatment plannning in the areas of achieving measurable goals and objectives. |
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
The treatment plan updates did not discuss the progress towards accomplishing the prior treatment goals nor did they address the resolution or the reasoning for the formation of new goals in two of two client records, #1 and 3. Client record #8 was missing a treatment plan update.
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Plan of Correction
MWFHE, Inc. Clinical Director/Supervisor will review treatment plan updates to ensure that counselor are working with clients towards goal accomplishments, such as addressing meeting goals. The Clinical Director /Supervisor will also meet with counselors to address deficiencies pertaining treatment plan updates. Any deficienices found will be correced by June 4, 2007. MWFHE, Inc. will continue to provide trainings for all clinical staff in regards to creating treatment plans. Trainings will be focus on helping staff in the areas of accomplishing treatment goals, and the reasoning for forming new goals for clients. |
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 two of three client records reviewed. Specifically, client records # 1 and 8 did not contain a case consultation.
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Plan of Correction
Clinical Director/Supervisor will review all clients charts to ensure that client's have had case consulations performed at least on a 60 day period. If case consualtions have not been completed Clinical Director/Supervisor will meet with counselor to up date charts. This update will be completed by June 4, 2007. MWFHE, Inc will provide trainings to ensure that case consultations are performed correctly. |
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
One of three aftercare plans were missing, client record # 4. Two of two aftercare plans, client record #1 and 3, were missing goals and support services were generalized into a checklist and not reflective of the individual client needs.
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Plan of Correction
Clinical Director/Supervisor will review client's aftercare plan for completion of aftercare plan, deficienices will be address by the Clinical Director/Supervisor with the counselor and corrections will be completed by June 4, 2007. Clinical Director/Supervisor will contiune to review client's charts to ensure that aftercare plan are done correctly. MWFHE, INc. will continue to provide trainings to staff. |
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
One of four discharge records that were reviewed, record number 4 was missing a discharge summary. Three of three discharge summaries, #1, 2, and 3, did not include reasons for treatment, and the services offered were either missing or incomplete. Two of three discharge summaries, #1 and 2, had generic statements as the response to treatment or focused on the reason for discharge. The status of discharge was missing in record #1 and incongruent with the type of discharge in record #2.
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Plan of Correction
Clinical Director/Supervisor will review all client's charts for discharge summary completions. Upon review of client's charts, if any discharge summaries are not completed Clinical Director/Supervisor will meet with counselor to ensure that discharge summaries are correctled by June 4, 2007. Clinical Director/Supervisor will continue to review client's chart on a monthly basic to ensure that all information regarding discharges are completed. MWFHE, INc. will provide training to clinical staff in the area of discharging. |
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 has not been conducted according to policy for all discharged clients reviewed, records #1, 2, 3 and 4.
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Plan of Correction
Clinical Supervisor will ensure that the follow-up policy for discharged clients be adhered to as per MWFHE Drug and Alcohol Manual. Clinical Supervisor along with the clinical staff will review discharged client's chart to ensure follow-ups have been performed on all discharged clients. This proces will be completed my July 9, 2007. Clinical Supervisor will perform on going chart reviews on discharged clients to ensure that the follow-up are done on a 30 and 60 day period. Clinical Supervisor will meet with staff to perform in-house trainings on MWFHE, INc. Follow-up procedure. |