INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 6, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguisher, located in the chart room, was last inspected in July, 2020.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Director of Program Operations will ensure that MWFHE maintenance manager have all the fires extinguishers inspected annually when the fire extinquisher company come out to inspect. The Director of Operation will also create a sign-off sheet with a list of all the fire extinquishers in our facility and give to the maintenance manager as he does the walkthrough with the fire inspector annualy and this will ensure that none of the fire estinquisher are miss. The Director of operations will also complete a walk through after the fire extinquisher company and the maintenance mananger complete the inspection to ensure that all fire extiquisher are inspected.
FYI: the fire extinquisher company came out today 7/11/22 and inspected all the fire extinqusher at our facilites. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's June 2021 through June 2022 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills. The facility utilized the main door exit route during all fire drills conducted during the period reviewed.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The director of operations will conduct a fire drill training for the staff responsible for conducting the MWFHE fire drills. This training will include fire drills doucumention, timeframe of drills, alternate exit route and other fire drills procedures. The "How to,conduct a Fire Drill "In-Service" training will be noted in MWFHE 2022-23 traiing log book along with the staff sign-in sheet. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's June 2021 through June 2022 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
The facility's hours of operation were listed as Monday and Wednesday from 9:00AM to 3:00PM, and Tuesday, Thursday, and Friday from 9:00AM to 8:00PM. All the fire drills conducted, during the reviewed period, were completed during the 12:00PM to 1:00PM hour. There were no fire drills conducted during the morning or evening hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The director of operations will conduct a fire drill training for the staff responsible for conducting the MWFHE fire drills. This training will include fire drills doucumention, timeframe of drills (including different days of the week) , alternate exit route and other fire drills procedures. The "How to,conduct a Fire Drill "In-Service" training will be noted in MWFHE 2022-23 traiing log book along with the staff sign-in sheet. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed 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 for the project's preceding fiscal year, based on an administrative review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO/Director of Program Operations have submitted a request for a Financial Audit waiver for 2021-2022. Waiting for a response from DDAP.
If the exemption is not granted the CEO will ensure and/or make every effort that a financial audit is conducted no later than 12/15/2022
As we know financial audits are very costly for organizations and it's very difficult to ensure that funds will be available for this cost in programs; We all know that Covid-19 Pandemic has caused financial hardship for majority of licenses program. Post-Covid-19 MWFHE is still getting back on track financially however, we are continuously pushing through and applying for grant opportunity for other cost including, Financial audit. MWFHE will do our best to get the financial audit completed no later than 12/15/2022
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709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in two of seven client records reviewed
Client #1 was admitted on August 9, 2021 and active at time of inspection. There were release of information forms the funding source and the urinalysis laboratory that were signed and dated by the witness on August 9, 2021; however, the dated signature of the client was not documented on either release form.
Client #4 was admitted on September 10, 2021 and was discharged on October 11, 2021. There were release of information forms the funding source and the urinalysis laboratory that were signed and dated by the witness on September 10, 2021; however, the dated signature of the client was not documented on either release form.
This is a repeat citation from the June 21, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The new Clinical Quality Assurance (Chart Audit) Cooridinator will ensure that all client records, date and client signature will be on all the release of information forms moving forward. This will be verified through weekly chart audit forms conducted by the CQA staff and documented in a binder; As well as, review weekly and discuss at the weekly clinical team meeting. Any issues or concerns regarding missing and/or obtaiing clients signatures/date on the release of information forms will be discueed and noted at the weekly clinical meeting and put in the meeting minute. |
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
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in two of three applicable client records reviewed.
Client #2 was admitted on September 1, 2021 and was active at the time of inspection. The comprehensive treatment plan was completed on September 20, 2021, and the first update was due no later than November 20, 2021; however, the update was not completed as of the date of the inspection.
Client #3 was admitted on September 8, 2021 and was active at the time of inspection. The comprehensive treatment plan was completed on September 29, 2021, and the first update was due no later than November 29, 2021; however, the update was completed on March 1, 2022.
This is a repeat citation from the June 21, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The new clinical supervisor will ensure that treatment and rehabilitation plans for clients served are reviewed and updated at least every sixty days by counselors; new clinical supervisor will conduct a training on Treatment Pln requirement for all counselors to ensure they have have the knowledge and skills needed to comply with treatment plan regulation and timeframe;
The new Clinical Quality Assurance (Chart Audit) Coordinator will also ensure that all client treatment plans
are completed in the required timeframe through his weekly chart audit process; he will also infromed the clinincal supervisor of his chart audit finding. This will be verified through weekly chart audits forms, reminders email to couselors of what clinincal docuemtnation is due; this will be documented suoervisoin notes as well as the chart audit binder; treatment Plan reviews will be discuss at the weekly clinical team meeting. Any issues or concerns regarding treatment plan will be discussed and noted at the weekly clinical meeting and put in the meeting minute. |
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.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in two of three applicable client records reviewed.
Client #2 was admitted on September 1, 2021 and was active at the time of inspection. The comprehensive treatment plan, dated September 20, 2021, documented weekly individual counseling sessions. There was no documentation, in the record, of weekly individual counseling session occurring during the weeks of January 2, 2022 - January 15, 2022, January 23, 2022 - February 5, 2022, and February 13, 2022 - March 12, 2022.
Client #3 was admitted on September 8, 2021 and was active at the time of inspection. Both, the comprehensive treatment plan, dated September 29, 2021, and the treatment plan update, dated March 1, 2022, documented weekly individual counseling sessions. There was no documentation, in the record, of weekly individual counseling sessions occurring during the weeks of February 6, 2022 - February 12, 2022, February 20, 2022 - February 26, 2022, and March 6, 2022 - March 26, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The new Clinical supervisor will ensure that all counseling services are provided and documentation completed
according to a client individual treatment and rehabilitation plan.
This will be verified through weekly chart audit forms conducted by the CQA staff and documented in a binder; As well as weekly chart review between the counselor and clinical supervisor.
Training for staff on clinical documentation requirements will be conducted throughout including no show notes mandatory for charts if clients does not show.
Any issues or concerns the CQI cooridinator have regarding non-compliance client chart specifically, missing weekly individual sessions then the CQI staff will meet with clinical supervisor to resolve. All non-compliance clients chart issues will be discuss and noted at the weekly clinical team meeting and put in the meeting minute.
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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 maintain a complete client record, which is to include case consultation notes, in three of three applicable client records reviewed.
Client #1 was admitted on August 9, 2021 and was active at the time of inspection. There was no documentation of case consultation notes as of the date of the inspection.
Client #2 was admitted on September 1, 2021 and was active at the time of inspection. There was no documentation of case consultation notes as of the date of the inspection.
Client #3 was admitted on September 8, 2021 and was active at the time of inspection. There was no documentation of case consultation notes as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The new Clinical supervisor will ensure to maintain a complete client record by ensuring that case consultation notes are in client charts when applicable.
This will be verified through weekly chart audit forms conducted by the CQA staff and documented in a binder; As well as weekly chart review between the counselor and clinical supervisor.
Training for staff on clinical documentation requirements will be conducted throughout including how to write a case consultation notes when required.
Any issues or concerns the CQI cooridinator have regarding non-compliance client chart specifically, missing case consultation then the CQI staff will meet with clinical supervisor to resolve. All non-compliance clients chart issues will be discuss and noted at the weekly clinical team meeting and put in the meeting minute. |