INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 7, 2008 through April 8, 2008 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 and a plan of correction is due on May 9, 2008.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to document the educational qualifications for counselor in one of six records reviewed, #8.
|
Plan of Correction
Men & Women For Human Excellence, Inc. (MWFHE) will ahere to the Department of Health, Divison of Drug and Alcohol Program Licensure staffing regulations under staffing regulations, 28 Pa. Code 704, qualifications for degree in a related field, when interviewing applicants for possible employment as counselor. In response to counselor #8 who was not within qualification of a counselor with his master degree in education, counselor #8 education background was re-submitted with his BA in criminal justice, in was review by Division of D & A program licensure and passed, counselor #8 is a counselor with a file #136391. Clinical Director with review staff records bi-monthly to ensure code 704, under staff requirments are adhere to. |
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.
|
Observations
Based on a review of personnel and training records, the facility failed to document TB/STD training in one of eight records reviewed, #1.
|
Plan of Correction
Men & Women For Human Excellence's, Inc. (MWFHE)Clinical Director will ensure that all staff members is enrolled in TB/STD training by the date of June 10, 2008. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant inspection conducted on April 7, 2008 at 15:00, the facility failed to ensure portable heaters were not within the facility. A portable space heater was located in the billing office on the third floor of the facility.
|
Plan of Correction
MWFHE, Inc. will ahere to the Department of Health, Division of Drug and Alochol Program licensure section 705.26 Heating and cooling that facilities may not permanent heaters that are not permanently mounted. Also MWFHE, inc. will ensure that space heaters are no longer kept within the clinical office space areas. The Executive Director will conduct inspection twice per year to ensure that sapce heaters are not being used within the facility. |
709.22(e)(1) 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:
(1) Activities and accomplishments of the preceding year.
|
Observations
Based on a review of the annual report, the facility failed to document the activities and accomplishments of the preceding year.
|
Plan of Correction
The President/CEO and Executive Director will establish within MWFHE, Inc. annual report the documentation of MWFHE, INc. activities and accomplishemnts. |
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.
|
Observations
Based on a review of the annual report, the facility failed to include a statement disclosing the names of officers, directors and principal shareholders.
|
Plan of Correction
The President/CEO and Executive Director will ensure to disclose in MWFHE, INc. annual report a list of the agency's officers, directors and principal shareholders. This information will be reported each year within MWFHE, INc. annual report. |
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.
|
Observations
Based on a review of facility policy and personnel records, the facility failed to document performance evaluations in the time frames identified in the facility's own policies in four of five records reviewed, #1, 2, 3 and 4. The project's policy stated that performance evaluations were due after the first 3 months of employment and annually thereafter on the anniversary date. Performance evaluations were completed five months late in record #1; three months late in records #2 and 3; and five months late in record #4.
|
Plan of Correction
The Executive Director will update MWFHE, Inc. Drug and Alcohol Manual to state that the performace evaluations for staff will be completed on a six (6) month period. Also the Executive Director will be responsible for conducting personnel record review of MWFHE staff. The review will take place twice per year to ensure compliance of MWFHE, Inc. Drug and Alcohol Manual. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records, the facility failed to document a notification of termination in one of one record reviewed, #9. The client was identified as an "administrative discharge" but there was no documentation that the client was given a written notice of termination.
|
Plan of Correction
MWFHE, Inc. will conduct in-house trainings on "How to complete Discharge Summaries" within 30 days to ensure that all staff are trained on to complete discharges. Also the clinical supervisor will review all client records at least once per month to ensure that proper forms and documentation have been completed. This process will include the checking of discharge forms and the type of dischage that each client will be receiving. While reviewing discharges the clinical supervisor will check for dischage items such as notification of termination. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on a review of client records on April 8, 2008, the facility failed to document a complete drug and alcohol history in three of seven records reviewed, #1, 6 and 7. The drug and alcohol history was not done and the client was admitted to treatment on 10/29/07 in record #1. The drug and alcohol history did not include a date of completion to verify that the history was completed within the project's own 30-day time frame in record #6. The drug and alcohol history was completed 30 days later than the project's 30-day time frame in record #7.
|
Plan of Correction
As of the date listed above the clinical supervisor has began to review client's records at least once per month, this process will be an on-going procedure. With the review of client's records on a monthly period it will allow for the clinical supervisor to ensure that all documents are completed within the thirty (30) day time frame (Int Tx plan,Bio,Clinical evalu., comp tx pl, ect). |
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.
|
Observations
Based on a review of client records, the facility failed to document complete and timely drug and/or alcohol histories in three of seven client records reviewed, #1, 6 and 7. #1 was not completed at the time of the inspection and the client was admitted to treatment on 10/29/07. #6 lacked a date of completion to verify that the history was completed within the project's own 30-day timeframe. #7 was completed 30 days later than the project's 30-day timeframe for the completion of the history.
|
Plan of Correction
MWFHE will conduct in-house trainings with clinical staff on how to complete Bio-psychosocial forms. Also the Clinical Supervisor will review client's record at least once per month to insure that timeframes are meet witin the 30-day timeframe period. As the timeframe period get closer the clinical supervisor will meet with the counselor to ensure that 30-day period is completed. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records on April 8, 2008, the facility failed to document complete psychosocial evaluations in six of seven records reviewed, #1, 2, 3, 4, 5 and 6. A psychosocial evaluation was missing in one of seven records, #1. Psychosocial evaluations did not include an assessment of the client's problems and needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and attitude towards treatment in five of seven records reviewed, #2, 3, 4, 5 and 6.
|
Plan of Correction
The clinical supervisor will review clients records on a monthly period to ensure that psychosocial evaluations are completed within the timeframe period. The clinical director will also conduct trainings to ensure that all clinical staff have a understanding of how to complete psychosocial evaluations and how to idenfy assessment needs such as assets/strengths, support systems, coping mechanisms. |
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.
|
Observations
Based on a review of client records, the facility failed to document short and long-term goals in terms of measurable criteria in seven of seven client records reviewed, #1, 2, 3, 4, 5, 6 and 7.
|
Plan of Correction
The Clinical Director will conduct on-site trainings with clinical staff on how to complete and document short and long-term goals also during the training there will be topics on how to measure goals within measurable criteria. After the on-site training the clinical director will do a on-site testing to measure the clinical staff understanding of the training. The Clinical Supervisor will also review client's charts at least once per month to ensure that treatment plans are completed and goals both long and short are reviewed. |
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.
|
Observations
Based on a review of client records, the facility failed to document complete treatment plan updates in six of six records reviewed, #2, 3, 4, 5, 6 and 7. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the prior treatment plans in four of six client records reviewed, #2, 3, 4 and 5. Treatment plan updates were not completed every sixty days in two of six client records reviewed, #6 and 7.
|
Plan of Correction
The clinical supervisor will review client's record at least once per month to ensure that treatment plan updates are completed in the proper timeframe period. Also MWFHE will conduct on-site trainings with its clinical staff on treatment plan and updated treatment plans with the focus being on how to properly assess clients for updated treatment plan completion, example idenfing if a client has made progress or not with their individual goals, how to document moving clients to the next level of achieving their goals. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records on April 8, 2008, the facility failed to document that counseling services were provided according to the individual treatment plan in seven of seven client records reviewed, #1, 2, 3, 4, 5, 6 and 7. Treatment plans indicated that individual sessions should occur on a weekly basis.
Weekly individual treatment sessions were not documented from 2/15/08 through 4/8/08 in client record #1.
Weekly individual treatment sessions were not documented from 10/11/07 through 12/17/07 and from 12/19/07 through 4/8/08 in record #2.
Weekly individual treatment sessions were not documented from 11/12/07 through 12/16/07 and from 12/18/07 to 1/2/08 in record #3.
Weekly individual treatment sessions were not documented from 1/22/08 through 2/12/08 and from 2/14/08 through 3/9/08 in record #4.
Weekly individual treatment sessions were not documented from 10/26/07 through 11/27/07 and from 12/27/07 through 1/22/08 in record #5.
Weekly individual treatment sessions were not documented from 11/1/07 through 4/3/08 in record #6.
Weekly individual treatment sessions were not documented from 1/30/08 through 3/3/08, when the client was discharged, in record #7.
None of the above records contained any documentation from the facility regarding the clients' absence from treatment or any attempts to reengage clients in treatment.
|
Plan of Correction
The clinical supervisor will meet weekly with each counselor and provide supervision, during this session the counselor's case load will be reveiwed to determine if all clients have be see on contacted for their individual session. If a client has not attendent their individual session for the week the counselor will document a plan for contacting the client and when the session will be rescheduled. During supervision, counselors will be remineded that all client's should be seen at least once per week. |
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.
|
Observations
Based on a review of client records on April 8, 2008, the facility failed to document case consultations at least quarterly in four of seven records reviewed, #1, 2, 6 and 7. Case consultations were missing.
|
Plan of Correction
The clinical supervisor will review client's records at least once per month to ensure that case consultations are completed within the proper timeframe. Also MWFHE, perform on-site trainings on how to complete case consultations and completing them in the timeframe that is assigned. |
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.
|
Observations
Based on a review of client records, the facility failed to document complete discharge summaries in four of four records reviewed, #7, 8, 9 and 10. Discharge summaries did not indicate the specific reason(s) for the client seeking treatment, the client's response to treatment plan goals or services offered in treatment.
|
Plan of Correction
The clinical supervisor will review all discharges when they are completed by clinical staff to ensure that specific reason for discharge are indicated, document client's response to treament plan goals and services to be offered after treament. Also MWFHE, will conduct on-site trainings on how to complete dischage summaries. |