INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12-14, 3011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Men and 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of personnel records, the facility failed to provide documentation of meetings for the new clinical supervisor for the first six months of employment.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. As part of the inspection the employee record for the clinical supervisor, employee #3 , was reviewed. Employee #3 was hired for the position of clinical supervisor on 9/12/11. A review of her employee file failed to substantiate that documented meetings with her supervisor had been occurring since her hire date.
Facility staff stated that the documents were available and were asked to produce those documents. The necessary documentation was not forthcoming during the course of the inspection.
The findings were reviewed with the project and facility director and were not disputed.
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Plan of Correction
The Program Director shall provide supervision to the clinical supervisor. The Program Director will meet with the clinical supervisor at least once per month for the first six months and such meetings shall be documented and maintained in the personnel file. The personnel file shall be reviewed, monthly, by the office manager for compliance. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of employee records, the facility failed to document the supervised period for the counselor assistant on the staff roster for the required time period.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. As part of the inspection employee records were reviewed. One employee was identified as a counselor assistant(#10). Employee # 10 was hired on 6/6/10 according to the "Staffing Requirements Facility Summary Report". There was no documentation of close supervision for this employee from 6/6/10 to 12/14/11. Though the information was requested, facility staff failed to produce the documentation.
The findings were reviewed with the project and facility directors and were not disputed.
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Plan of Correction
Counselor (#4) has been assigned to provide supervision to counselor assistant (#10); all such supervision shall be documented and placed in #10's personnel file. The standard that relates to the noted deficiency shall be reviewed with all staff taking on supervision of counselor assistant responsibilities and monitored for compliance by the clinical supervisor on a monthly basis. |
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
Based on the review of the facility policy and procedure manual and administrative documents provided onsite, the facility failed to document an overall training plan to address staff training needs.
The findings included:
During the onsite licensing renewal inspection conducted from December 12-14, 2011, the facility policy and procedure manual and supplemental administrative documents were reviewed. The manual contained a policy which stated that the program director would develop a staff training plan based on the assessment of staff training needs annually by January 31. The facility director was asked to provide a copy of the staff training plan. The plan was not provided during the inspection.
The findings were reviewed with the project and facility directors and were not disputed.
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Plan of Correction
The Program Director shall develop an overall training plan for addressing staff needs. The plan shall be based on the assessment of staff training needs which should address training subjects, trainers, and proposed dates of training. The Executive Director or designee shall review the policy and procedural manual, where the plan is to be maintained, at least four times per year to confirm compliance with standard.
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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
Based on the review of the facility policy and procedure manual and administrative documents provided onsite, the facility failed to document an evaluation of the training plan for the 2010 training year..
The findings included:
The onsite licensing renewal inspection was conducted from December 12-14, 2011. The facility manual contained a policy which stated that the program director would complete an evaluation of the staff training plan for the previous training year by January 31. The Facility Director was asked to provide a copy of the evaluation. The document was not provided during the inspection.
The findings were reviewed with the project and facility directors and were not disputed.
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Plan of Correction
The program director shall document an evaluation of the training plan for the 2010 and 2011 training years and place such documentation in the policy and procedural manual. Upon placement of the evaluation in the policy and procedural manual, the executive director shall be notified in order that an immediate review can be conducted to ensure compliance with this standard. Also, the program and executive director shall conduct annual reviews of the policy and procedural manual to confirm ongoing compliance with this standard |
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
Based on the review of employee personnel and training records, the facility failed to document an individual training plan on each staff person annually.
The findings included:
During the onsite licensing renewal inspection conducted from December 12-14, 2011, 12 employee training and personnel records were reviewed. Each employee is required to have a training plan documented within one month of their hire date and then annually thereafter. Three of the twelve employee records did not include documentation of annual training plans.
Employee # 3 was hired on 9/12/11. This record did not contain documentation of an individual training plan.
Employee # 10 was hired on 6/16/10. This record did not contain documentation of an individual training plan.
Employee # 12 was hired on 9/2/11. No individual training plan was documented in this record.
The findings were reviewed with the Project and Facility Director and were not disputed.
This is a repeat citation.
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Plan of Correction
The clinical supervisor has documented an annual written individual training plan for employee # 3, #10, and #12 appropriate to their skill level. The office manager shall review the personnel file of each new hire within 30 days of hire to confirm compliance with this standard and MWFHE policy. |
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
Based on the review of employee training and personnel records and staff schedules, the facility failed to ensure that a sufficient number of staff certified in CPR and trained in First Aid were on duty during all of the facility's hours of operation.
The findings included:
Twelve employee records were reviewed during the onsite licensing renewal inspection of December 12-14, 2011. Six staff were trained in First Aid. Two staff had current CPR certification. In addition to the Drug and Alcohol treatment staff reviewed, one Mental Health staff person had current CPR and First Aid. When the names of staff on duty at any given time were compared to the list of staff who were trained in CPR and First Aid, the documentation revealed that there was insufficient coverage each day from 6:30 PM to 8:00 PM.
The findings were reviewed with the facility director and were disputed, but the facility director did not provide any additional supporting documentation to demonstrate compliance with the regulation.
This is a repeat citation.
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Plan of Correction
MWFHE shall provide on-site and off-site CPR certification and first aid training to all clinical and non-clinical staff persons in order to have sufficient number of staff persons onsite during the project's hours of operations. The office manager shall review staff files on a monthly basis to confirm compliance with State standard and MWFHE policy. Also, MWFHE shall immediately schedule at least two current staff persons with CPR and First Aid training on the 8am - 4pm and 4pm - 8pm shifts. The Program Director shall monitor compliance of this schedule
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the "Staffing Requirements Facility Summary Report" and listings of counselor caseloads, the facility failed to ensure that each caseload was limited to 35:1.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. All active client caseload lists were reviewed in addition to the "Staffing Requirements Facility Summary Report". Based on the clinical hours and caseload numbers reflected on the "Staffing Requirements Facility Summary Report", employee # 4 had a caseload of 36:1.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
MWFHE shall limit counselor caseload to 35 active clients or less. There shall be a minimum of one FTE counselor for every 35 clients in any phase of outpatient treatment. The clinical supervisor and office manager shall monitor counselor caseload on a daily basis to confirm compliance with this standard/policy. Employee #4 caseload has been reduced to adhere to State standard. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection and observations of the staff and client utilization of physical space at the facility, the facility failed to ensure that all counseling areas provided privacy so that counseling sessions could not be seen or heard from outside the counseling room.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. Division staff were assigned office space to work each day during the inspection. On December 12, 2011, Division staff were assigned to use the physician's office. This office is located on the second floor at the rear of the facility. In order to gain access to the office, staff or clients have to walk through an individual counseling office located at the top of the stairs. During the inspection, Division staff observed the individual counseling office being used for individual counseling sessions with clients. Administrative staff who were securing information needed by Division staff for review would walk through the counseling office to access the physician's office. When the facility director was asked about whether this was a regular occurrence, he acknowledged that it was. In addition to the obvious concerns about routine interruptions of individual counseling sessions, Division staff became aware that everything being said in the counseling office could be heard through the door and wall of the physician's office. Counseling was not provided in a confidential setting.
The findings were reviewed with the Project and Facility Director and were not disputed.
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Plan of Correction
MWFHE shall ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. The agency has ordered white noise machines that are placed outside offices to block noise. Also, the office next to the physician's office is no longer used for counseling sessions. Counseling sessions are now provided in a confidential setting. The Program director and or clinical supervisor shall regularly inspect for compliance of this standard
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill record and the facility policy and procedure manual, the facility failed to adhere to the facility requirement that clients and staff evacuate the building in less than one minute during routine fire drills.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. The fire drill documentation and policy manual were reviewed on December 12, 2011. Written facility policy required that the building be evacuated in under one minute. Documentation of the fire drills conducted during the previous twelve months revealed that the evacuation time for each drill exceeded the one minute permitted by facility policy and procedure.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
MWFHE has made arrangements with a fire safety expert to determine an acceptable evacuation time for our building; the time shall be specified in writing. The Executive Director and/or designee shall monitor fire drill evacuation time for compliance. Also, the Program Director shall revise related policy to reflect the time determined by the fire safety expert.
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709.22(c)(4) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(4) Frequency of meetings.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to document that the frequency of governing body meetings occurred as specified in the Corporate
By-Laws at four times per year.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. Facility staff were asked to provide copies of the board of directors meeting minutes a number of times on December 12 and 13, 2011 but the meeting minutes were not provided. A written list of required information was given to the Clinical Director which included another request for the Board of Director's Meeting Minutes. The Board Meeting Minutes were never produced.
Article 5, Section 1 of the facility's Corporate By-Laws stated that the Board of Directors would meet four times per year. No documentation was provided to verify that the meetings occurred.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The Governing body for MWFHE shall meet at least every other month. Minutes of such meetings shall be made available to demonstrate compliance with this standard/policy. The Executive Director shall monitor this standard/policy for ongoing compliance.
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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.
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Observations
Based on a review of the facility policy and procedure manual and supplemental administrative documentation, the facility failed to provide documentation of the annual report which was required to include documentation of the activities and accomplishments for calendar year 2010.
The findings included:
An onsite licensing renewal inspection was conducted on December 12-14, 2011. As part of the inspection, facility staff were asked to provide a copy of the annual report for the 2010 calendar year. The annual report was not included as part of the administrative documentation kept in the facility manual. A copy of the annual report was requested verbally and in writing during the inspection. A copy of the annual report was not provided during the course of the inspection and there was no documentation of the activities and accomplishments for calendar year 2010.
The findings were reviewed with the Project and Facility Directors and were not disputed.
This is a repeat citation.
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Plan of Correction
The governing body of MWFHE shall make available to the public an annual report which includes activities and accomplishments of the preceding year. The executive director has documented such report and has placed it in the policy and procedural manual. A copy of the report is currently available. The executive director will monitor continued compliance with this standard via annual reviews of the manual. |
709.22(e)(2) 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:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the facility policy and procedure manual and supplemental administrative documentation, the facility failed to provide documentation of the annual report which was required to include documentation of a financial statement of income and expenses for calendar year 2010.
The findings included:
An onsite licensing renewal inspection was conducted on December 12-14, 2011. As part of the inspection, facility staff were asked to provide a copy of the annual report for the 2010 calendar year. The annual report was not included as part of the administrative documentation kept in the facility manual. A copy of the annual report was requested verbally and in writing during the inspection. A copy of the annual report was not provided during the course of the inspection and there was no documentation a financial statement of income and expenses for calendar year 2010.
The findings were reviewed with the Project and Facility Directors and were not disputed.
This is a repeat citation.
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Plan of Correction
The governing body of MWFHE shall make available to the public an annual report which includes documentation of a financial statement of income and expenses for calendar year 2010. The executive director has documented such report and has placed it in the policy and procedural manual. A copy of the report is currently available. The executive director will monitor continued compliance with this standard via annual review of the manual.
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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 facility policy and procedure manual and supplemental administrative documentation, the facility failed to provide documentation of the annual report which was required to include documentation of a statement disclosing the names of officers, directors and principal shareholders for calendar year 2010.
The findings included:
An onsite licensing renewal inspection was conducted on December 12-14, 2011. As part of the inspection, facility staff were asked to provide a copy of the annual report for the 2010 calendar year. The annual report was not included as part of the administrative documentation kept in the facility manual. A copy of the annual report was requested verbally and in writing during the inspection. A copy of the annual report was not provided during the course of the inspection and there was no documentation of a statement disclosing the names of officers, directors and principal shareholders for calendar year 2010.
The findings were reviewed with the Project and Facility Directors and were not disputed.
This is a repeat citation.
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Plan of Correction
The governing body of MWFHE shall make available to the public an annual report which includes documentation of a statement disclosing the names of officers, directors and principal shareholders for calendar year 2010. The executive director has documented such report and has placed it in the policy and procedural manual. A copy of the report is currently available. The executive director will monitor continued compliance with this standard via annual review of the manual.
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on the review of the facility policy and procedure manual, the Project Director failed to document an annual review of the project policies and procedures.
The findings included:
The Facility policy and procedure manual was reviewed. on December 12, 2011. There was no documentation in the manual that the Project Director had completed his annual review of the policies and procedures.
The findings were reviewed with the Project and Facility Director and were not disputed.
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Plan of Correction
The program director shall prepare and annually update a written manual delineating project policies and procedures. The program director shall document the updating by dated signature. The executive director shall monitor ongoing compliance of standard via review of manual.
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709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of the facility policy and procedure manual and supplemental administrative documentation, the facility failed to document collaboration between the Project Director and the governing body in the formulation of the facility's annual goals and objectives.
The findings included:
An onsite licensing renewal inspection was conducted December 12-14, 2011. The documentation provided did not include any documented evidence of collaboration between the governing body and the Project Director for the purpose of developing the facility's annual goals and objectives.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The program director will assist the governing body in formulating policy and shall present the following to the governing body at least annually (including the year 2012): Project goals and objectives which include time frames and available resources; written reports of project operations; and a performance report summarizing the progress towards meeting goals and objectives. Such collaboration shall be documented by the program director, maintained in the agency's policy and procedure manual and reviewed, quarterly.
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709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of the facility policy and procedure manual and supplemental administrative documentation, the facility failed to document annual goals and objectives for January 1, 2011 through December 31, 2011.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. The documentation provided did not include any documented evidence of facility goals and objectives for 2011.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The program director shall document annual goals and objectives for January 1, 2012 through December 31, 2012 and maintain annual goals in the policy and procedural manual. The executive director shall annually review policy and procedural manual and confirm and document ongoing compliance with this standard |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a review of the facility policy and procedure manual and supplemental administrative documentation, the facility failed to document a performance report on the annual goals and objectives for 2010.
The findings included:
An onsite licensing renewal inspection was conducted December 12-14, 2011. The documentation provided did not include any report of the facility's progress relative to the goals and objectives for 2010.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The program director shall document performance reports on the annual goals and objectives for 2010 and 2011 and maintain such report in the policy and procedural manual. Upon placement of the performance reports in the policy and procedural manual, the executive director shall be notified in order that an immediate review can be conducted to ensure compliance with this standard. Also, the program and executive director shall conduct annual reviews of the policy and procedural manual to confirm ongoing compliance with this standard. |
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
Based on a review of the facility policy and procedure manual and supplemental administrative documentation, the facility failed to document current letters of agreement with primary referral sources.
The findings included:
An onsite licensing renewal inspection was conducted December 12-14, 2011. The documentation provided did not include current letters of agreement. Letters of agreement with ten agencies in the Philadelphia area were on file. All of them expired in June or July of 2011 and were not renewed.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The program director shall document current letters of agreement with primary referral sources and maintain such letters in the policy and procedural manual. The executive director shall annually review policy and procedural manual to confirm and document ongoing compliance with this standard. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of the facility policy and procedure manual and supplemental administrative documentation, the facility failed to document a current letter of agreement which documented the availability of 24 hour emergency medical and 24 hour emergency psychiatric services..
The findings included:
An onsite licensing renewal inspection was conducted on December 12-14, 2011. The documentation provided did not include any documented evidence of a letter of agreement for 24 hour emergency medical coverage. There was a letter of agreement for emergency psychiatric services on file that expired in March of 2006. A second agreement with a local psychiatric facility was documented and current but made no mention of 24 hour emergency psychiatric coverage. There was no documented evidence of a current written agreement with a licensed hospital or physician for the provision of 24 hour emergency psychiatric and medical coverage.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The Program Director shall document a current letter of agreement which documents the availability of 24 hour emergency medical and 24 hour emergency psychiatric services; such letter(s) shall be maintained in the policy and procedural manual. The executive director shall annually review policy and procedural manual to confirm and document ongoing compliance with this standard. |
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 the review of financial statements presented to Division staff, the facility failed to document an annual audit for the Fiscal Year ended 12/31/2010.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. On December 12, 2011 the facility was asked to provide documentation of the facility's annual audit. Facility staff presented an Independent Auditors Report.
The independent auditor's report confirmed that the review of the financial statements did not rise to the level of an audit.
The findings were discussed with the Project and Facility Directors on December 12, 2011 and were disputed.
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Plan of Correction
The Executive Director shall document a completed 2010-2011 audit. The Program Director shall immediately, upon completion, place the audit in the policy and procedural manual to be available for onsite inspection(s). The Executive and Program Directors shall annually review the policy and procedural manual to confirm and document ongoing compliance with this standard. |
709.26(a)(5) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(5) Working hours.
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Observations
Based on a review of the facility policy and procedure manual and supplemental administrative documentation, the facility failed to document a policy on work hours that was consistent with actual practice.
The findings included:
An onsite licensing renewal inspection was conducted December 12-14, 2011. Personnel policies and procedures stated that the standard work week was 37.5 hours but the "Staffing Requirements Facility Summary Report" form lists the standard work week as 40 hours.
This issue was addressed during the licensing inspection completed in July of 2011. The facility was advised to update the policy to reflect actual practice. The policy update did not occur. Facility policy and procedure is not consistent with actual practice.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The program director shall document a policy on work hours that is consistent with a 40 hour workweek. Such policy shall be maintained in the policy and procedural manual and annually reviewed by the governing body to confirm and document ongoing compliance with this standard. |
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
Based on a review of the facility policy and procedure manual and supplemental administrative documentation, the facility failed to document an affirmative action plan or current EEO grid reflecting compliance with fair employment practices.
The findings included:
An onsite licensing renewal inspection was conducted December 12-14, 2011. The documentation provided included a staffing composition grid from 2009. There has been turnover for most of the clinical team in the past year. The staff composition grid was not updated. Division staff afforded facility staff the opportunity to provide a current grid by 11:15 A.M. on 12/13/2011. Facility staff failed to comply with this request.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The program director has documented a staff composition grid that is maintained in the policy and procedural manual for annual inspection. The Executive Director shall annually review the policy and procedural manual to confirm and document ongoing compliance with this standard. |
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
Based on a review of employee records, the facility failed to document reference checks on each employee.
The findings included:
An onsite licensing renewal inspection was conducted December 12-14, 2011. Written facility policy and procedure on selection of new staff stated that three reference checks would be completed on candidates prior to hire. Twelve employee records were reviewed during this inspection. Seven of these employees were hired within the past year. Documentation of reference checks was not included in three personnel records ( # 3, 7, 12).
The findings were reviewed with the Project and Facility Directors and were not disputed.
This is a repeat citation.
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Plan of Correction
Reference checks have been completed and documented for personnel records (#3, 7, and 12). The office manager shall review each new hire's personnel file within one month from the date of hire to confirm ongoing compliance with this standard. |
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 policy and procedure manual and supplemental administrative documentation, the facility failed to document a written procedure which was consistent with 4 Pa. Code Subsection 255.5.
The findings included:
An onsite licensing renewal inspection was conducted December 12-14, 2011. 4 Pa. Code Subsection 255.5 was not addressed in its entirety. The written procedure did not address 4 Pa. Code Subsections 255.5 (a)(1) through (a)(10). Only 4 Pa. Code Subsection 255.5 (b) was addressed. The policy section that addressed 4 Pa. Code Subsection 255.5 (b) stated that one of the circumstances which would permit disclosure of client information without consent was "oral representation client consent". State law at 71 P.S. Subsection 1690.108 (b) and federal regulation at 42 CFR Part 2, Subpart C, Subsection 2.31 (a) require the client's written consent to disclosure.
One consent form which is routinely used for releases of information to funding entities states that a "brief summary of relapse" may be released. This is inconsistent with 4 Pa. Code Subsection 255.5(b) which limits the amount of information that can be disclosed to third party payers. One of the parameters allows, with the client's written consent, "A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse". This is not consistent with "brief summary of relapse" which can be interpreted to include information from the client history.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
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. The Program Director shall develop policy and procedure consistent with the entirety of 4 Pa. Code Subsection 255.5 (including Pa code Subsections 255.5 (a) (1) through (a) (10). Staff has been instructed to remove the statement, "A brief summary of relapse" and replace it with, "A short statement of relapse and frequency." |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a review of client records and the physical plant inspection, the facility failed to secure client records within locked storage containers.
The findings included:
An onsite licensing renewal inspection was conducted December 12-14, 2011. Written facility policy and procedure stated that records would be kept in a locked storage room and that the Project Director had the key and would control access.
Records of clients receiving drug and alcohol treatment were observed in an unsecured location within a second floor counseling office. The client records were stored in cardboard file boxes. Most of these were closed client records but there were also three active records observed in the same unsecured location on December 13, 2011. Clinical staff were informed at that time that client records were located in an unsecured area. The following day, December 14, 2011, the area was inspected again and the records were in the same location in the counselor's office and remained unsecured.
Contrary to written policy and procedure, the Project Director was not the only staff person with keys to the locked areas where records were kept. Clerical and clinical staff were observed freely accessing records as they needed to throughout the day. This was inconsistent with written facility policy.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The Program Director and Facility Director met with all staff to- review the policy and standard relating to proper maintenance of client records. All client records will be secured within locked storage containers. When in use by appropriate staff person(s), the record is to remain with that particular staff person at all times until no longer needed and then returned to the file room for proper storage. A checkout and check in log will be maintained at all time and closely monitored by the program and facility directors for ongoing compliance. The clinical supervisor will provide additional training to all staff directly relating to this standard and document such training in the personnel training log. |
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
Based on a review of client records, the facility failed to document informed and voluntary consents on complete consent to release information forms in 18 of 26 client records reviewed.
The findings included:
An onsite licensing renewal inspection was conducted on December 12-14, 2011. The facility policy and procedure manual and supplemental administrative documentation was reviewed. Written facility policy and procedure specifically addressed the form of a written consent as specified at 28 Pa. Code subsection 709.28(c)(1-6). Incomplete consents to release information where found in 18 of 26 client records reviewed.
Client record # 1- The client was admitted on 10/27/11 and last treated on 10/28/11. A consent to release "a brief summary of any decomposition" was designated for release to a Diagnostic company that processed urine for testing. It is unclear what information would be released relative to "decomposition" and hence does not constitute an informed consent.
Client record # 2- The client was admitted on 9/16/11 and last treated on 12/6/11. Consents to release information signed at the time of intake did not include specific information to be released to funding entities. The consent to release to the funding entity in this record failed to specify what information would be released. A consent to release "a brief summary of any decomposition" was designated for release to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent.
Client record # 3- The client was admitted on 8/23/11 and last treated on 12/8/11. A consent to release "a brief summary of any decomposition" was designated to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent.
Client record # 4- The client was admitted on 9/22/11 and last treated on 11/9/11. A consent to release "a brief summary of any decomposition" was designated to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent.
Client record # 5- The client was admitted on 8/23/11 and last treated on 8/26/11. A consent to release "a brief summary of any decomposition" was designated to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent.
Client record # 6- The client was admitted on 8/24/11 and last treated on 8/26/11. A consent to release "a brief summary of any decomposition" was designated to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent.
Client record # 7- The client was admitted on 9/13/11 and last treated on 10/13/11. A consent to release "a brief summary of any decomposition" was designated to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent.
Client record # 8- The client was admitted on 8/16/11 and last treated on 11/25/11. A consent to release "a brief summary of any decomposition" was designated to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent.
Client record # 14- The client was admitted on 9/14/11 and last treated on 12/5/11. A consent to release "a brief summary of any decomposition" was designated to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent.
Client record # 15- The client was admitted on 9/27/11 and last treated on 12/6/11. A consent to release "a brief summary of any decomposition" was designated for release to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent.
Client record # 17- The client was admitted on 10/31/11 and last treated on 12/5/11. Consents to release information signed at the time of intake did not include specific information to be released and did not identify what information would be released. The client's signature was not dated on the forms.
Client record # 18- The client was admitted on 8/2/11 and last treated on 12/6/11. A consent to release "a brief summary of any decomposition" was designated for release to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent.
Client record # 19- The client was admitted on 10/12/11 and last treated on 12/9/11. Consents to release information signed at the time of intake did not include specific information to be released and did not identify to whom the information would be released.
Client record # 22- The client was admitted on 10/12/11 and last treated on 12/6/11. A consent to release "a brief summary of any decomposition" was designated for release to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent. One consent in the record did not identify the specific information to be released.
Client record # 23- The client was admitted on 11/3/11 and last treated on 12/7/11. A consent to release "a brief summary of any decomposition" was designated for release to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent.
Client record # 24- The client was admitted on 9/27/11 and last treated on 11/29/11. A consent to release "a brief summary of any decomposition" was designated for release to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent.
Record # 25- The client was admitted on 9/16/11 and last treated on 11/29/11. A consent to release "a brief summary of any decomposition" was designated for release to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent.
Record # 26- The client was admitted on 9/26/11 and last treated on 11/29/11. A consent to release "a brief summary of any decomposition" was designated for release to a Diagnostic company that processed urine for testing. It is unclear what would be released as part of "decomposition" and hence does not constitute an informed consent.
The findings were reviewed with the Project Director and the Facility Director and were not disputed.
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Plan of Correction
MWFHE shall obtain informed and voluntary consents from all clients for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to which disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Expiration date of the consent.
Also, The program director shall replace on the" Confidential Authorization Consent Form" that is included in the records of all active clients, the term, "A brief summary of any relapse episodes" or a brief summary of any decomposition" with the term, "A short statement of any relapse episodes" and place such form in the policy and procedural manual for annual inspection. The Executive Director shall review the revised form for compliance with State standards and randomly review clients records to confirm ongoing compliance. The program and facility directors shall monitor compliance via bi-weekly chart audits
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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
Based on the review of administrative and clinical documentation, the facility failed to implement a data collection and record keeping system that allowed for efficient retrieval of needed information.
The findings included:
Division staff conducted an onsite licensing renewal inspection from December 12-14, 2011. During the course of the inspection facility staff were asked to provide documentation necessary to complete the licensing inspection. The materials requested included, but were not limited to: the annual training assessment, plan and evaluation; the annual administrative goals and objectives for 2011; the performance report on goals and objectives for 2010; supervisory notes for the clinical supervisor who was hired on September 12, 2011; documentation of counselor assistant supervision notes; Board of Director's meeting minutes; a current staff composition grid; and client records. The materials requested were, in most instances, never produced though the Facility Director stated that they were available.
The findings were reviewed with the facility staff and were not disputed.
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Plan of Correction
The Program Director shall arrange for additional on-site and off-site training for staff directly relating to this standard. We have retained the services of a data entry expert who shall assist MWFHE in improving our current data collection system. The expert shall also provide training for relevant staff persons and will also advise us in the acquisition of additional equipment. The Program Director or designee shall monitor the effective use of the current data collection processes and make recommendations to the Executive Director for improvements.
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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.
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Observations
Based on the review of client records , the facility failed to notify each client in writing of a decision to involuntarily terminate them from treatment.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. Eighteen full client records were reviewed at that time. Three of these records were of clients who had been involuntarily terminated from treatment by the Project staff.
Client record # 5- The client was admitted on August 23, 2011 and discharged on September 29, 2011. No letter of involuntary termination was documented in the client record at the time of the record inspection on December 13, 2011.
Client record # 6- Client was admitted on 8/24/11 and discharged on 10/1/11. No letter of involuntary termination was documented in the client record at the time of the record inspection on December 13, 2011.
Client record # 7- Client was admitted on 9/13/11 and discharged on 10/13/11. No letter of involuntary termination was documented in the client record at the time of the record inspection on December 13, 2011.
The findings were reviewed with the Facility and Project Directors and were not disputed
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Plan of Correction
The Facility and Clinical Directors facilitated documentation training. A form letter was introduced and distributed to staff to notify clients of involuntary termination. Additional training shall be provided by the facility and clinical directors when deemed necessary. The clinical supervisor will conduct bi-weekly audits of all records closed within the past 90 day to confirm ongoing compliance with this standard/policy. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records , the facility failed to notify clients in writing of the client's right to appeal a decision by the facility to involuntarily terminate them from treatment in three of three client records.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. Eighteen full client records were reviewed at that time. Three of these records were of clients who had been involuntarily terminated from treatment by project staff.
Client record # 5- The client was admitted on 8/23/11 and discharged on 9/29/11. No letter of termination or notification of the client's right to appeal the decision to terminate his/her treatment was documented in the client record at the time of the record inspection on December 13, 2011.
Client record # 6- The client was admitted on 8/24/11 and discharged on 10/1/11. No letter of termination or notification of the client's right to appeal the decision to terminate his/her treatment was documented in the client record at the time of the record inspection on December 13, 2011.
Client record # 7- The client was admitted on 9/13/11 and discharged on 10/13/11. No letter of termination or notification of the client's right to appeal the decision to terminate his/her treatment was documented in the client record at the time of the record inspection on December 13, 2011.
The findings were reviewed with the Facility and Project Directors and were not disputed.
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Plan of Correction
The Facility and Clinical Directors facilitated documentation training. A form letter was introduced and distributed to staff to notify clients of their right to have an opportunity to request reconsideration of a decision terminating treatment. Additional training shall be provided on an ongoing basis. The clinical supervisor shall monitor, via bi-weekly audit reviews, to confirm ongoing compliance with this standard. |
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
Based on the review of client records, the facility failed to document complete, detailed personal histories which addressed family, legal, employment/vocational, educational, military, recreational and sexual historical information in six of twenty six client records.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. Six of twenty six client records reviewed were missing all or part of the personal history. Written facility policy and procedure requires that the personal history be done within 30 days for each client admitted.
Client record # 5- The client was admitted on 8/23/11 and remained in an active status until 9/29/11. The personal history was not completed.
Client record # 14- The client was admitted on 9/14/11 and last treated on 12/5/11. The personal history failed to document details of the client's family interrelationships. Legal history was incomplete. Comments in the history stated that the client had no legal history but comments on the Axis V diagnosis was that he was mourning the death of a family member while incarcerated. The client work history only accounted for the years to 2005 with no comments about how the client currently supports himself.
Client record # 15- The client was admitted on 9/27/11 and last treated on 12/6/11. The personal history failed to document details of the client's family interrelationships. The educational history indicated that the client dropped out of school in the 7 th grade due to D&A use but provided no pertinent details about other areas of his life impacted at that age or whether the client had interest in furthering his education. No detail on the client's recreational interests was documented. The sexual history did not include information relative to a report of an issue of serial relationships.
Client record # 17- The client was admitted on 10/31/11 and last treated on 12/5/11. The personal history failed to document details of the client's family interrelationships. The record indicated that the client dropped out of school in the 7 th grade due to an accident but did not provide any additional detail except that when he returned to school he was unable to keep up. The issue of possible learning disabilities was not explored.
Client record # 18- The client was admitted on 8/2/11 and last treated on 12/6/11. The personal history failed to document details of the client's family interrelationships. employment, educational or recreational history. The record documented very specific thoughts and plans regarding suicidal/homicidal ideation that the client was having and then in the margin next to the comments, staff noted that the client had no plan or intent regarding suicide/homicide.
Client record # 19- The client was admitted on 10/20/11 and last treated on 12/9/11. The personal history failed to document details of the client's family interrelationships, employment and recreational history.
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The findings were reviewed with the Project and Facility Directors and were not disputed.
This is a repeat citation.
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Plan of Correction
The Facility and Clinical Director with all clinical staff present conducted documentation training. Clinical staff was instructed on clinical information gathering. They were instructed on the appropriate manner to document complete, detailed personal histories which addressed family, legal, employment/vocational, educational, military, recreational and sexual historical information.
The Program Director and Clinical Director will conduct ongoing monthly documentation trainings. Counselors will be instructed on clinical information.
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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
Based on the review of client records, the facility failed to document complete psychosocial evaluations in thirteen of twenty six client records reviewed.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. The psychosocial evaluations were incomplete in thirteen of 26 client records reviewed.
Client record # 2- The client was admitted on 9/16/11 and last treated on 12/6/11. The psychosocial evaluation failed to include support systems, coping mechanisms and the client's attitude toward treatment.
Record # 3- The client was admitted on 8/23/11 and last treated on 12/8/11. The psychosocial evaluation failed to include the client's assets/strengths, support systems, coping mechanisms, negative factors impacting treatment, the client's attitude toward treatment and the clinical impressions of the counselor.
Record # 4- The client was admitted on 9/22/11 and last treated on 11/9/11. The psychosocial evaluation failed to include the client's assets/strengths, support systems, coping mechanisms, the client's attitude toward treatment and the clinical impressions of the counselor.
Record # 8- The client was admitted on 8/16/11 and last treated on 11/25/11. The psychosocial evaluation failed to include the client's underlying needs or problems, assets/strengths, support systems, coping mechanisms, negative factors impacting treatment, the client's attitude toward treatment and the clinical impressions of the counselor.
Record # 14- The client was admitted on 9/14/11 and last treated on 12/5/11. The psychosocial evaluation failed to include the client's coping mechanisms and the counselor's clinical impressions of the client's underlying needs and problems.
Record # 15- The client was admitted on 9/27/11 and last treated on 12/6/11. The psychosocial evaluation failed to include the client's assets/strengths, coping mechanisms, attitude toward treatment and the clinical impressions of the counselor.
Record # 18- The client was admitted on 8/2/11 and last treated on 12/6/11. The psychosocial evaluation failed to include a composite picture of the client, support systems, coping mechanisms and the clinical impressions of the counselor.
Record # 19- The client was admitted on 10/20/11 and last treated on 12/9/11. The psychosocial evaluation failed to include a composite picture of the client, the client's assets/strengths, support systems, coping mechanisms, negative factors impacting treatment, the client's attitude toward treatment and the clinical impressions of the counselor.
Record # 22- The client was admitted on 10/12/11 and last treated on 12/6/11. The psychosocial evaluation failed to include the client's assets/strengths, support systems, coping mechanisms, negative factors impacting treatment, the client's attitude toward treatment and the counselor's clinical impressions.
.Record # 23- The client was admitted on 11/3/11 and last treated on 12/7/11. The psychosocial evaluation failed to include support systems, coping mechanisms, negative factors impacting treatment and the client's attitude toward treatment.
Record # 24- The client was admitted on 9/27/11 and last treated on 11/29/11. The psychosocial evaluation failed to include the client's underlying needs, assets/strengths, support systems, coping mechanisms, negative factors impacting treatment, the client's attitude toward treatment and the clinical impressions of the counselor.
Record # 25- The client was admitted on 9/16/11 and last treated on 11/29/11. The psychosocial evaluation failed to include the client's underlying needs, assets/strengths, support systems, coping mechanisms, negative factors impacting treatment, the client's attitude toward treatment and the clinical impressions of the counselor.
Record # 26- The client was admitted on 9/26/11 and last treated on 11/25/11. The psychosocial evaluation failed to include the client's assets/strengths, support systems, coping mechanisms, negative factors impacting treatment, the client's attitude toward treatment and the clinical impressions of the counselor.
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The findings were reviewed with the Project and Facility Directors and were not disputed.
This is a repeat citation.
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Plan of Correction
The Facility and Clinical Director with all clinical staff present conducted documentation training. Clinical staff was instructed on clinical information gathering. They were instructed on the appropriate manner to document and complete psychosocial evaluations. The Program Director and Clinical Director will conduct ongoing monthly documentation trainings. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the frequency of treatment on the treatment plan in eight of eighteen client records.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. Eight of eighteen client records reviewed included treatment plans that were missing documentation of the frequency of treatment.
Client record # 2- The client was admitted on 9/16/11 and last treated on 12/6/11. The treatment plan included the type of services to be offered to the client but did not include a frequency for each type of service offered.
Client record # 3- The client was admitted on 8/23/11 and last treated on 12/8/11. The treatment plan included the type of services to be offered to the client but did not include a frequency for each type of service offered.
Client record # 4- The client was admitted on 9/22/11 and last treated on 11/9/11. The treatment plan included the type of services to be offered to the client but did not include a frequency for each type of service offered.
Client record # 5- The client was admitted on 8/23/11 and remained in an active status until 9/29/11. The treatment plan included the type of services to be offered to the client but did not include a frequency for each type of service offered.
Client record # 6- The client was admitted on 8/24/11 and last treated on 12/6/11. The treatment plan included the type of services to be offered to the client but did not include a frequency for each type of service offered.
Client record # 14- The client was admitted on 9/14/11 and last treated on 12/5/11. The treatment plan included the type of services to be offered to the client but did not include a frequency for each type of service offered.
Client record # 15- The client was admitted on 9/27/11 and last treated on 12/6/11. The treatment plan included the type of services to be offered to the client but did not include a frequency for each type of service offered.
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Client record # 18- The client was admitted on 8/2/11 and last treated on 12/6/11. The treatment plan included the type of services to be offered to the client but did not include a frequency for each type of service offered.
The findings were reviewed with the Project and Facility Directors and were not disputed.
This is a repeat citation.
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Plan of Correction
The Facility and Clinical Director with all clinical staff present conducted documentation training. Clinical staff was instructed on clinical information gathering. They were instructed on the appropriate manner to document the frequency of treatment on treatment plans. The Program Director and Clinical Director will conduct ongoing monthly documentation trainings. |
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 the review of client records and the facility policy and procedure manual, the facility failed to document treatment plan updates within the time frames specified in written facility policy in six of ten client records. Additionally, treatment plan updates did not consistently address the client's progress on the stated goals of the previous treatment plan in six of ten client records.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. Ten client records required documentation of treatment plan updates. Six client records included documentation of treatment plan updates that were either late or incomplete.. Written facility policy and procedure requires that the updates be documented every 30 days for clients admitted to the Intensive Outpatient Program (IOP). All clients in the record sample were admitted to the IOP level of care.
Client record # 2- This active client was admitted on 9/16/11 and last treated on 12/6/11. The treatment plan was formulated on 10/14/11. A treatment plan update was documented on 11/7/11. A treatment plan update was missing for 12/7/11. There was no documentation of the treatment plan update as of 12/14/11.
Client record # 8- This active client was admitted on 8/16/11 and last treated on 11/25/11. The treatment plan was formulated on 10/12/11. Treatment plan updates were documented on 8/16/11 and 11/8/11. Treatment plan updates were missing for September 2011, October 2011 and December 2011.
Client record # 14- This active client was admitted on 9/14/11 and last treated on 12/5/11. The treatment plan was formulated on 9/14/11. A treatment plan update was documented on 11/14/11. The treatment plan update in the record failed to address progress on the stated goals of the treatment plan. Treatment plan updates were missing for October 2011 and December 2011.
Client record # 15- This active client was admitted on 9/27/11 and last treated on 12/6/11. The treatment plan update in the record failed to address the client's progress on the stated goals of the treatment plan.
Client record # 18- The client was admitted on 8/2/11 and last treated on 12/6/11. The treatment plan update in the record failed to address the client's progress on the stated goals of the treatment plan.
Client record # 23- The client was admitted on 11/3/11 and last treated on 12/7/11. The treatment plan was formulated on 11/3/11. The treatment plan update failed to address the client's progress on the stated goals of the treatment plan.
Client record # 24- The client was admitted on 9/27/11 and last treated on 11/29/11. The treatment plan was formulated on 10/27/11, the update was documented on 11/25/11. The update did not address progress on the stated goals of the treatment plan.
Client record # 25- The client was admitted on 9/16/11 and last treated on 11/29/11. The treatment plan was documented on 10/12/11. Treatment plan updates were documented on 11/8/11 and 12/8/11. The client's progress on the stated goals of the treatment plan was not documented.
Client record # 26- The client was admitted on 9/26/11 and last treated on 11/25/11. The treatment plan was formulated on 10/28/11. A treatment plan update was documented on 11/29/11 but failed to include documentation of the client's progress on the stated goals of the treatment plan.
The findings were reviewed with the Project and Facility Directors and were not disputed.
This is a repeat citation.
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Plan of Correction
The Facility and Clinical Director with all clinical staff present conducted documentation training. Clinical staff was instructed on the timely manner of completing treatment plans updates. Staff was informed that treatment plans updates are due, per facility policy, every 30 days or less. In addition to timeliness, treatment plan updates require consistent documentation of client's progress on stated goals of the previous treatment plan. |
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 the review of the facility policy and procedure manual and client records, the facility failed to document case consultations in time frames that were consistent with written facility policy and procedure in 15 of 17 client records.
The findings included:
During the onsite licensing renewal inspection conducted from December 12-14, 2011, twenty-six client records were reviewed. Seventeen client records required documentation of case consultations every 30 days. Fifteen were not done within timeframes specified in written facility policy. Written facility policy addressing case consultations stated that case consultations would be done at a minimum of every 90 days. It further addressed conditions requiring case consultations as follows: within two weeks of admission; during a change to another level of care; within two weeks prior to discharge; for the purpose of counselor training; failure to respond to treatment.
Client record #2 - The client was admitted on 9/16/11 and last treated on 12/6/11. The treatment plan was completed on 10/14/11. No case consultation was held within the required two week period .
Client record # 3 - The client was admitted on 10/23/11 and last treated on 12/8/11. No case consultation was documented within the required two week period .
Client record # 4 - The client was admitted on 9/22/11 and last treated on 12/2/11. No case consultation was documented within the required two week period .
Client record # 5- The client was admitted on 8/23/11 and last treated on 8/26/11 and discharged on 9/29/11. The client did not return for treatment and no case consultation was documented within the required two week period to make a determination as to how to proceed.
Client record #6 - The client was admitted on 8/24/11, last treated on 8/26/11 and discharged on 10/1/11. The client did not return for treatment and no case consultation was documented within the required two week period to make a determination as to how to proceed.
Client record # 7 - The client was admitted on 9/13/11 and last treated on 10/13/11 . No case consultation was documented within the required two week period.
Client record # 8 - The client was admitted on 8/16/11 and last treated on 11/25/11. No case consultation was documented within the required two week period.
Client record # 14 - The client was admitted on 9/14/11 and last treated on 12/5/11. No case consultation was documented within the required two week period.
Client record # 16- The client was admitted on 8/30/11, last treated on 9/19/11 and discharged on 10/19/11. The client did not return for treatment and no case consultation was documented within the required two week period to make a determination as to how to proceed.
Client record # 17- The client was admitted on 10/31/11 and last treated on 12/5/11 . No case consultation was documented within the required two week period .
Client record # 18- The client was admitted on 8/2/11 and last treated on 12/6/11 . No case consultation was documented within the required two week period.
Client record # 19 - The client was admitted on 10/20/11 and last treated on 12/9/11. No case consultation was documented within the required two week period.
Client record # 22 - The client was admitted on 10/12/11 and last treated on 12/6/11. No case consultation was documented within the required two week period.
Client record # 23 - The client was admitted on 11/3/11 and last treated on 12/7/11. No case consultation was documented within the required two week period.
Client record # 24 - The client was admitted on 9/27/11 and last treated on 11/29/11. No case consultation was documented within the required two week period.
Client record # 25 - The client was admitted on 9/16/11 and last treated on 11/29/11. No case consultation was documented within the required two week period.
Client record # 26 - The client was admitted on 9/26/11 and last treated on 11/25/11. No case consultation was documented within the required two week period.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The Program Director shall revise agency policy relating to this standard to indicate that case consutation shall be completed 90 days (or less) from the date of admission and every 90 days or less thereafter. The Program and Clinical supervisor will inform all clinical staff of the revised policy. The clinical superviaor will monitor compliance with this standard via bi-weekly chart audits. Also, case consultations will be completed by primary counselors for all active clients who have not received one. The clinical supervisor will monitor for compliance and report to Program Director all results. |
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
Based on the review of the facility policy and procedure manual and client records, the facility failed to document aftercare goals which included time frames for completion in two of two client records.
The findings included:
During the onsite licensing renewal inspection conducted December 12-14, 2011, twenty six client records were reviewed. Two client records were those of successfully discharged clients. Two of two client records reviewed failed to include documentation of timeframes for the completion of goals identified in the aftercare plan.
Client record # 20- This client was admitted on 8/3/09 and discharged on 7/5/11. The goals on the aftercare plan did not contain timeframes for completion.
Record # 21- This client was admitted on 8/19/10 and discharged on 9/29/11. The goals on the aftercare plan did not contain timeframes for completion.
The findings were reviewed with the Facility and Project Directors and were not disputed.
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Plan of Correction
The Facility and Clinical Director with all clinical staff present conducted documentation training. Clinical staff was instructed on the appropriate documentation of aftercare goals which include time frames for completion of goals identified in the aftercare plan. The Program Director and Clinical Director will conduct ongoing monthly documentation trainings to reinforce information. |
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
Based on the review of client records, the facility failed to document discharge summaries which addressed the client's response to treatment and the reasons for treatment in four of six client records.
The findings included:
An onsite licensure renewal inspection was conducted December 12-14, 2011. Client records were inspected on December 13 and 14. Seven records reviewed were those of discharged clients and required a discharge summary. Four of six client records included discharge summaries that were missing the reasons that brought the client into treatment for the current treatment episode or the client's response to treatment.
Client record # 4- The client was admitted on 9/22/11 and discharged on 12/2/11. The discharge summary in this record failed to include documentation of the reasons that prompted the client to seek treatment for this treatment episode and the client's response to treatment.
Client record # 5- The client was admitted on 8/23/11 and discharged on 9/2911. The discharge summary in this record failed to include documentation on the client's response to treatment.
Client record # 6- The client was admitted on 8/24/11 and discharged on 10/1/11. The discharge summary in this record failed to include documentation on the client's response to treatment.
Client record # 21- The client was admitted on 8/19/10 and discharged on 9/29/11. The discharge summary in this record failed to include documentation on the reasons that prompted the client to seek treatment for this treatment episode.
The findings were reviewed with the Project and Facility directors and were not disputed.
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Plan of Correction
The Facility and Clinical Director with all clinical staff present conducted documentation training. Clinical staff was instructed on the appropriate documentation of discharge summaries which address the client's response to treatment and the reasons for treatment. The Program Director and Clinical Director will conduct ongoing monthly documentation trainings to reinforce appropriate documentation |
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 the review of client records and the facility policy manual, the facility failed to document follow up as required by written facility policy and procedure in six of seven client records.
The findings included:
An onsite licensure renewal inspection was conducted December 12-14, 2011. Client records were inspected on December 13 and 14. Seven client records reviewed were those of discharged clients and required documentation of follow up in compliance with written facility policy and procedure. Facility policy required that follow up be documented at 30, 60 and 90 days.
Client record # 5- The client was admitted on 8/23/11 and discharged on 9/29/11. Follow up documentation was recorded on 10/31/11, but was missing for 11/30/11.
Client record # 6- The client was admitted on 8/24/11 and discharged on 10/1/11. Follow up documentation was recorded on 11/1/11 but was missing for 12/1/11.
Client record # 9- The client was admitted on 4/25/11 and discharged on 5/25/11. Follow up documentation was recorded on 6/27/11 but was missing for 7/27/11 and 8/27/11.
Client record # 10- The client was admitted on 5/2/11 and discharged on 6/2/11. Follow up documentation was recorded on 7/4/11 but was missing for 8/4/11 and 9/4/11.
Client record # 12- The client was admitted on 5/16/11 and discharged on 6/16/11. Follow up documentation was recorded on 7/4/11 but was missing for 8/16/11 and 9/16/11.
Client record # 21- The client was admitted on 8/19/10 and discharged on 9/29/11. No follow up documentation was observed in the record. Documentation of follow up was missing for 10/29/11 and 11/29/11.
The findings were reviewed with the Project and Facility Directors and were not disputed.
This is a repeat citation.
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Plan of Correction
The Facility and Clinical Director with all clinical staff present conducted documentation training. Clinical staff was instructed on the appropriate documentation of follow up procedures as required by written facility policy and procedure. The Program Director and Clinical Director will conduct ongoing monthly documentation trainings to reinforce appropriate documentation. |
709.94(f)(1) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(1) Identifying persons in need of project services.
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Observations
Based on the review of the facility policy procedure manual and supplemental administrative materials provided by the Clinical Director and Facility director, the facility failed to document an outreach plan which included a strategy and persons responsible for implementing a method to identify those in need of project services.
The findings included:
An onsite licensure renewal inspection was conducted from December 12-14, 2011. There was no documentation of an outreach plan which included who would be responsible to identify persons in need of project services and the methodology to be utilized to accomplish this task.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The Clinical Director and Facility director shall collaborate in the development, documentation and implementation of an outreach plan that will include a strategy and persons responsible for implementing a method to identify those in need of project services and the methodology to be utilized to accomplish this task. The Executive Director shall conduct an annual review of the policy and procedural manual to confirm compliance with this standard. |
709.94(f)(2) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(2) Alerting persons and their families to the availability of project services.
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Observations
Based on the review of the facility policy procedure manual and supplemental administrative materials provided by the Clinical Director and Facility director, the facility failed to document an outreach plan which included a strategy and persons responsible for implementing a method for alerting persons and families to the availability of project services.
The findings included:
An onsite licensure renewal inspection was conducted from December 12-14, 2011. There was no documentation of an outreach plan which included who would be responsible for alerting persons and families to the availability of project services and the methodology to be utilized to accomplish this task.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The Clinical Director and Facility director shall collaborate in the development and documentation of an outreach plan that will include a strategy and persons responsible for implementing a method for alerting persons and families to the availability of project services. The Executive Director shall conduct an annual review of the policy and procedural manual to confirm compliance with this standard. |
709.94(f)(3) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(3) Encouraging persons to utilize the service delivery system.
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Observations
Based on the review of the facility policy and procedure manual and supplemental administrative materials provided by the Clinical Director and Facility director, the facility failed to document an outreach plan which included a strategy and persons responsible for implementing a method for encouraging persons and families to utilize project services.
The findings included:
An onsite licensure renewal inspection was conducted from December 12-14, 2011. There was no documentation of an outreach plan which included who would be responsible for encouraging persons to utilize the delivery system of project services and the methodology to be utilized to accomplish this task.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The Clinical Director and Facility director shall collaborate in the development and documentation of an outreach plan that includes a strategy and persons responsible for implementing a method for encouraging persons and families to utilize project services. Such plan, upon completion, shall be maintained in the agency's policy and procedural manual. The Clinical Director and Facility Directors shall annually review the manual to confirm ongoing compliance with this standard
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on the review of client records, the facility failed to document a physician's signature on treatment plans or treatment plan updates for clients funded through Medical Assistance and Healthchoices funding streams.
The findings included:
An onsite licensing renewal inspection was conducted from December 12-14, 2011. At that time eighteen full client records were reviewed. Seventeen of seventeen applicable records failed to include documentation of the physician's signature on treatment plans and treatment plan updates as required by Title 55 Part III( relating to the Medical Assistance Manual).
Client record # 1 - The client was admitted on 10/27/11. The preliminary treatment plan was formulated on 10/27/11. No physician signature was affixed to this document.
Client record # 2 - The client was admitted on 9/16/11. The preliminary treatment plan was formulated on 9/16/11. The comprehensive treatment plan was formulated on 10/14/11. Treatment plan updates were documented on 10/13/11, 11/11/11 and 12/8/11. There was no documentation of the physician's signature affixed to any of these documents.
Client record # 3 - The client was admitted on 8/23/11. The preliminary treatment plan was formulated on 8/23/11. The comprehensive treatment plan was formulated on 9/15/11. There was no documentation of the physician's signature affixed to any of these documents.
Client record # 4 - The client was admitted on 9/22/11. The preliminary treatment plan was formulated on 9/22/11. The comprehensive treatment plan was formulated on 10/21/11. A treatment plan updates were documented on 11/23/11. There was no documentation of the physician's signature affixed to any of these documents.
Client record # 5- The client was admitted on 8/23/11. The preliminary treatment plan was formulated on 8/23/11. No physician signature was affixed to this document.
Client record # 6 - The client was admitted on 8/24/11. The preliminary treatment plan was formulated on 8/24/11. There was no documentation of the physician's signature affixed to any of these documents.
Client record # 8 - The client was admitted on 8/16/11. The preliminary treatment plan was formulated on 8/16/11. The comprehensive treatment plan was formulated on 10/12/11. Treatment plan updates were documented on 11/8/11. There was no documentation of the physician's signature affixed to any of these documents.
Client record # 14 - The client was admitted on 9/14/11. The preliminary treatment plan was formulated on 9/14/11. The comprehensive treatment plan was formulated on 10/14/11. Treatment plan updates were documented on 11/14/11. There was no documentation of the physician's signature affixed to any of these documents.
Client record # 15 - The client was admitted on 9/27/10. The preliminary treatment plan was formulated on 9/27/10. The comprehensive treatment plan was formulated on 10/26/10. Treatment plan updates were documented on 12/28/10, 3/8/11, 5/9/11, 7/12/11, 9/12/11 and 11/8/11. There was no documentation of the physician's signature affixed to any of these documents.
Client record # 16 - The client was admitted on 8/30/11. The preliminary treatment plan was formulated on 8/30/11. No physician signature was affixed to this document.
Client record # 18 - The client was admitted on 8/2/11. The preliminary treatment plan was formulated on 8/2/11. The comprehensive treatment plan was formulated on 9/8/11. Treatment plan updates were documented on 10/7/11, 11/4/11 and 12/2/2011. There was no documentation of the physician's signature affixed to any of these documents.
Client record #19 - The client was admitted on 10/20/11. The preliminary treatment plan was formulated on 10/20/11. The comprehensive treatment plan was formulated on 11/23/11. There was no documentation of the physician's signature affixed to any of these documents.
Client record # 22 - The client was admitted on 10/12/11. The preliminary treatment plan was formulated on 10/12/11. The comprehensive treatment plan was formulated on 10/31/11. There was no documentation of the physician's signature affixed to any of these documents.
Client record # 23 - The client was admitted on 11/3/11. The preliminary treatment plan was formulated on 11/3/11. The comprehensive treatment plan was formulated on 12/2/11. There was no documentation of the physician's signature affixed to any of these documents.
Client record # 24 - The client was admitted on 9/27/11. The preliminary treatment plan was formulated on 9/27/11. The comprehensive treatment plan was formulated on 10/27/11. Treatment plan updates were documented on 11/25/11. There was no documentation of the physician's signature affixed to any of these documents.
Client record # 25 - The client was admitted on 9/16/11. The preliminary treatment plan was formulated on 9/16/11. The comprehensive treatment plan was formulated on 10/12/11. Treatment plan updates were documented on 11/8/11 and 12/8/11. There was no documentation of the physician's signature affixed to any of these documents.
Client record # 26- The client was admitted on 9/26/11. The preliminary treatment plan was formulated on 9/26/11. The comprehensive treatment plan was formulated on 10/28/11. Treatment plan updates were documented on 11/29/11. There was no documentation of the physician's signature affixed to any of these documents.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The Facility and Clinical Director with all clinical staff present conducted documentation training (treatment plans). Clinical staff was instructed on the appropriate sign-off of all treatment plans. The Program Director will revise all treatment plan forms to include a signature and date line for the physician in addition to the client and counselor signature and date line that is currently in place. The Program and Clinical Director will conduct ongoing monthly documentation trainings to reinforce appropriate documentation. Also, the clinical supervisor shall review client's records on a bi-weekly basis to confirm compliance with this policy.
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709.14(b)(4) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(4) Change in activity/discontinuance of an activity.
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Observations
Based on a review of client records and the current facility license, the facility was observed to be providing treatment services at the partial hospitalization level of care to seven of the 26 clients whose records were reviewed.
The findings included:
During the onsite licensing renewal inspection of December 12-14, 2011, twenty six client records were reviewed. Division staff observed that clients are routinely receiving treatment at the Intensive Outpatient Program (IOP) level of care. The IOP program is scheduled with three groups for three hours per week and one individual session per week that is typically one hour in duration. In order to provide this level of treatment, a partial hospitalization license would be required and this facility is only licensed to provide services at the outpatient level of care ( less than 10 hours per week). The following clients had services provided at 10 or more hours per week for at least part of the time they were in treatment at this facility:
Client record # 2- The client was admitted on 9/16/11 and last treated on 12/6/11. The record of service in this record revealed that services occurred at ten hours per week during the following weeks: 9/26/11, 10/3/11, 10/24/11, 11/7/11 and 11/14/11.
Client record # 3- The client was admitted on 8/23/11 and last treated on 12/8/11. The record of service in this record revealed that services occurred at ten hours per week during the following weeks: 9/12/11, 9/19/11, 9/26/11, 10/3/11 and 10/24/11.
Client record # 4- The client was admitted on 9/22/11 and last treated on 12/2/11. The record of service in this record revealed that services occurred at ten hours per week during the following weeks: 10/10/11, 10/7/11, 10/24/11 and 11/7/11.
Client record # 14- The client was admitted on 9/14/11 and last treated on 12/5/11. The record of service in this record revealed that services occurred at ten hours per week during the following weeks: 9/26/11, 11/7/11, 11/14/11 and 11/28/11.
Client record # 17- The client was admitted on 10/31/11 and last treated on 12/6/11. The record of service in this record revealed that services occurred at ten hours per week during the following weeks: 11/14/11.
Client record # 18- The client was admitted on 8/2/11 and last treated on 12/6/11. The record of service in this record revealed that services occurred at ten hours per week during the following weeks: 9/26/11, 10/3/11, 10/ 17/11, 10/24/11 and 11/14/11.
Client record # 19- The client was admitted on 10/20/11 and last treated on 12/9/11. The record of service in this record revealed that services occurred at ten hours per week during the following weeks: 11/14/11.
The findings were reviewed with the Project and Facility Directors and were not disputed.
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Plan of Correction
The program director met with clinical and non- clinical staff and instructed each of them to provide services at the outpatient level of care (less than 10 hours per week for IOP clients). Services at this rate will keep MWFHE in compliance with this standard. The Clinical Supervisor and Office Manager shall monitor scheduling on a weekly basis to- confirm ongoing compliance. |