INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the December 14, 2012 licensure renewal inspection. The follow-up inspection was conducted on April 20, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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704.11(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 a 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 include:
Eight employee records were reviewed on April 20, 2012. None of the employee records reviewed included documentation of current CPR certification and only one included documentation of first aid training. When the names of staff on duty were compared to the list of staff who had current CPR training and first aid training, the documentation revealed that there was insufficient coverage each day from 6:30 PM to 8:00 PM.
The clinical supervisor and facility director were not able to provide any additional documentation to dispute the finding.
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 person's 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 and Clinical supervisor shall monitor for compliance of this schedule. |
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 a review of the facility policy and procedure manual and observations during the plan of correction follow up inspection, 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 the annual review of the policies and procedures. The Facility Director was working on the updates and corrections in the manual at the time of the follow up inspection. The corrections and the Project Director review and signoff were not complete as of the plan of correction follow up inspection conducted on April 20, 2012.
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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 this standard via quarterly review of manual. |
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:
A plan of correction follow up inspection was conducted on April 20, 2012. The facility director was not able to produce a copy of the annual audit for the fiscal year ended 12/31/2010.
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Plan of Correction
The Executive Director shall document a completed 2010-2011 audit. The Executive 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, the facility failed to include documentation of a policy on work hours that was consistent with current facility practice. Facility policy and procedure describes a 37.5 hour work week, but the "Staffing Requirements Facility Summary Report" lists 40 hour work weeks for the counselors.
The findings include:
Personnel policies and procedures were reviewed on 4/20/12. The policy and procedure described a 37.5 hour work week. A review of the "Staffing Requirements Facility Summary Report" revealed that the facility was reporting 40 hour work weeks for the counselors and counselor assistants.
The Department of Health approved plan of correction indicated that this would be corrected by 1/31/2012.
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Plan of Correction
Men & Women for Human Excellence shall continue maintaining a 37.5 hour workweek. As such, the program director and clinical director shall ensure that the staffing form presented to Davidson staff shall indicate that a 37.5 hours week is the standard work week for MWFHEW. Also, the program director shall ensure that this policy is maintained in the policy and procedural manual and annually reviewed by the governing body to confirm and document ongoing compliance with agency policy and State 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, the facility failed to include policy and procedure on client confidentiality which was consistent with state law at 71 P.S. subsections 1690.102 through 1690.115; 4 Pa. Code subsection 255.5; 28 Pa. Code subsection 709.28 and federal regulations at 42 CFR Part 2, Subparts A through E.
The findings include:
A plan of correction follow up inspection was conducted on April 20, 2012. The written policies and procedures for client confidentiality in a drug and alcohol treatment facility were reviewed. The policy and procedure incorrectly referred to 55 Pa. Code subsection 5100, except that it did not refer to 55 Pa. Code subsection 5100.37 which is the only regulation that applies to drug and alcohol treatment records. Policy and procedures relative to 4 Pa. Code subsection 255.5 were incomplete and inaccurate. Policy and procedure that addressed the HIPAA regulations did not include a disclaimer that releases of information permitted by the HIPAA regulations which were prohibited by the drug and alcohol confidentiality regulations were still prohibited.
The deficiencies were reviewed with the Clinical Supervisor and were not disputed.
This is a repeat citation.
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Plan of Correction
MWFHE has reviewed and changed portions of its current policy and procedure with respect to this standard to include policy and procedure on client confidentiality that is consistent with state law at 71 P.S. subsections 1690.102 through 1690.115; 4 Pa. Code subsection 255.5; 28 Pa. Code subsection 709.28 and federal regulations at 42 CFR Part 2, Subparts A through E. References to 55 Pa. Code subsections 5100 has been removed and replaced with references to 55 Pa. Code subsections 5100.37 which is the only regulation that applies to drug and alcohol treatment records. Additionally, "Whenever information in a patient's records relates to drug or alcohol abuse or dependency, as defined in 71 P. S. § 1690.102, those specific portions of the patient's records are subject to the confidentiality provisions of section 8(c) of the Pennsylvania Drug and Alcohol Abuse Control Act (71 P. S. § 1690.108(c)), and the regulations promulgated there under, 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information)." This revised policy and procedure has been reviewed and approved by the Executive Director and placed in MWFHE policy and procedure manual |
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 the physical plant inspection, the facility failed to secure client records within locked storage containers.
The findings included:
A plan of correction follow up inspection was conducted on April 20, 2012. At approximately 9:30 AM the door to an unoccupied counselors office was open and fifteen (15) unsecured client records were observed on a shelf in that counseling office.
The findings were reviewed with the Clinical Supervisor and were not disputed.
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Plan of Correction
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 valid consent to release information forms in seven of seven client records.
The findings include:
A plan of correction follow up inspection was conducted on April 20, 2012. Consent to release information forms documented in seven of seven client records were not consistent with the content requirements for a valid consent.
Client record # 1, with an admission date of 2/10/12, included documentation of consent to release information forms that were missing the specific information that would be disclosed and the dated signature of a witness. The form also contained language specific to the HIPAA regulations which were in conflict with state law and regulation and federal regulation and suggested that releases of information without consent that were prohibited by state and federal law and regulation were acceptable. A "general consent" to release information was also included in the client record. The use of "general consent" to release information forms is prohibited at 42 CFR Part 2, Subpart C, subsection 2.32 and does not meet the requirements at 42 CFR Part 2, Subpart C, subsection 2.31(a).
Client record # 2, with an admission date of 1/13/2012, included documentation of consent to release information forms that were missing the specific information that would be disclosed and the dated signature of a witness. The form also contained language specific to the HIPAA regulations which were in conflict with state law and regulation and federal regulation and suggested that releases of information without consent that were prohibited by state and federal law and regulation were acceptable. A "general consent" to release information was also included in the client record. The use of "general consent" to release information forms is prohibited at 42 CFR Part 2, Subpart C, subsection 2.32 and does not meet the requirements at 42 CFR Part 2, Subpart C, subsection 2.31(a).
Client record # 3, with an admission date of 4/5/2012, included documentation of consent to release information forms that were missing dated signature of a witness. The form also contained language specific to the HIPAA regulations which were in conflict with state law and regulation and federal regulation and suggested that releases of information without consent that were prohibited by state and federal law and regulation were acceptable.
Client record # 4, with an admission date of 1/27/12, contained language specific to the HIPAA regulations which were in conflict with state law and regulation and federal regulation and suggested that releases of information without consent that were prohibited by state and federal law and regulation were acceptable. A "general consent" to release information was also included in the client record. The use of "general consent" to release information forms is prohibited at 42 CFR Part 2, Subpart C, subsection 2.32 and does not meet the requirements at 42 CFR Part 2, Subpart C, subsection 2.31(a).
Client record # 5, with an admission date of 1/31/12, contained language specific to the HIPAA regulations which were in conflict with state law and regulation and federal regulation and suggested that releases of information without consent that were prohibited by state and federal law and regulation were acceptable. A "general consent" to release information was also included in the client record. The use of "general consent" to release information forms is prohibited at 42 CFR Part 2, Subpart C, subsection 2.32 and does not meet the requirements at 42 CFR Part 2, Subpart C, subsection 2.31(a).
Client record # 6, with an admission date of 3/29/12, contained language specific to the HIPAA regulations which were in conflict with state law and regulation and federal regulation and suggested that releases of information without consent that were prohibited by state and federal law and regulation were acceptable. A "general consent" to release information was also included in the client record. The use of "general consent" to release information forms is prohibited at 42 CFR Part 2, Subpart C, subsection 2.32 and does not meet the requirements at 42 CFR Part 2, Subpart C, subsection 2.31(a).
Client record # 7, with an admission date of 2/3/12, contained language specific to the HIPAA regulations which were in conflict with state law and regulation and federal regulation and suggested that releases of information without consent that were prohibited by state and federal law and regulation were acceptable. A "general consent" to release information was also included in the client record. The use of "general consent" to release information forms is prohibited at 42 CFR Part 2, Subpart C, subsection 2.32 and does not meet the requirements at 42 CFR Part 2, Subpart C, subsection 2.31(a).
This was reviewed with the clinical supervisor who did not dispute the findings.
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Plan of Correction
A valid "consent to release information" form has been developed by MWFHE. The Program and Clinical Directors has met with clinical staff to review and discuss the updated form. Staff with caseloads of persons with substance abuse challenges has been instructed to complete the updated form during their next encounter with the persons on their caseload and also at that time to replace the old form with the new one. The Clinical Director shall monitor this standard for the next 60 days to ensure ongoing compliance with this standard. |
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 a plan of correction follow up inspection conducted on April 20, 2012, compliance with this regulation could not be determined because there were no client records that fell into this category of termination. Confirmation of compliance will be determined during future on site inspections. The original deficiency is listed below:
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 a plan of correction follow up inspection conducted on April 20, 2012, compliance with this regulation could not be determined because there were no client records that fell into this category of termination. Confirmation of compliance will be determined during future on site inspections. The original deficiency is listed below:
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 a review of client records, the facility failed to provide documentation of personal histories that included documentation of legal, military, recreational, educational and employment histories in five of six client records.
The findings include:
Components of the personal history were not documented in three of six client records reviewed.
Client record # 1 contained documentation of a personal history, but the personal history was missing the educational history.
Client record # 2 contained documentation of a personal history, but the personal history was missing the legal, employment, educational, recreational and sexual history components. The family history did not include documentation of family dynamics.
Client record # 4 contained documentation of a personal history, but the personal history was missing documentation of the employment history component.
Client record # 5 contained documentation of a personal history, but the personal history was missing documentation of the educational history component.
Client record # 6 contained documentation of a personal history, but the personal history was missing documentation of the legal and recreational components.
The findings were reviewed with the Clinical Supervisor and were not disputed.
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Plan of Correction
MWFHE shall ensure that documentation of clients personal histories include documentation of legal, military, recreational, educational and employment histories in all client records. The clinical supervisor shall provide additional training to all clinical staff relating to this standard. Clinical staff shall be informed that all components of the personal history require being addressed. Bi-weekly chart audits shall be conducted by the clinical supervisor to determine compliance with this standard. Any deficiencies found shall be addressed immediately by the primary clinician. The clinical supervisor shall recheck the record within 72 hours after alerting the primary therapist of the deficiency to ensure that the deficiency has been corrected. . Finally, the clinical supervisor shall ensure that a complete personal history is completed and placed in all of the client records that were inspected. |
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 a review of client records, the facility failed to document psychosocial evaluations that addressed all required areas and were evaluative in those areas for two of five client records.
The findings include:
Psychosocial evaluations were due in five of the client records reviewed. The evaluations were missing composite pictures, client's problems/needs, coping mechanisms, the clients' attitudes toward treatment and the counselor's conclusions and impressions.
Client # 2 was admitted on 1/13/12. Documentation of the psychosocial evaluation in the client record did not include a composite picture of the client, the client's problems and needs, the client's coping mechanisms and attitude toward treatment and the counselor's conclusions and impressions.
Client # 5 was admitted on 1/31/12. Documentation of the psychosocial evaluation did not include the client's support systems and coping mechanisms.
This was reviewed with the Clinical Supervisor and was not disputed.
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Plan of Correction
MWFHE shall ensure that documentation of psychosocial evaluations address all required areas and are evaluative in those areas. The clinical supervisor shall provide additional training to all clinical staff relating to this standard. Clinical staff shall be informed that all areas of the psychosocial evaluation require being addressed. . Bi-weekly chart audits shall be conducted by the clinical supervisor to determine compliance with this standard. Any deficiencies found shall be addressed immediately by the primary clinician. The clinical supervisor shall recheck the record within 72 hours after alerting the primary therapist of the deficiency to ensure that the deficiency has been corrected. Finally, the clinical supervisor shall ensure that a complete psychosocial evaluation is completed and placed in all of the client records that were inspected. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records and the facility policy and procedures, the facility failed to ensure that case consultations were documented in accordance with the time frames identified in facility procedure in two of two client records.
The findings included:
A plan of correction follow up inspection was conducted on April 20, 2012. Nine client records were reviewed. Two of those client records were due to include documentation of case consultations within two weeks of admission, but there was no documentation of a case consultation in either client record. 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, with an admission date of 1/13/12, did not include documentation of a case consultation. No case consultation was documented in the client record within the required two week period. There was no documentation of a case consultation within 90 days of admission.
Client record # 4, with an admission date of 1/27/12, did not include documentation of a case consultation. No case consultation was documented in the client record within the required two week period.
This was reviewed with the Clinical Supervisor who did not dispute the findings.
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Plan of Correction
The Program Director shall revise agency policy relating to this standard to indicate that case consultation 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 supervisor will monitor compliance with this standard via bi-weekly chart audits. |
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 a plan of correction follow up inspection conducted on April 20, 2012, compliance with this regulation could not be determined because there were no client records that were due to include documentation of aftercare planning. Confirmation of compliance will be determined during future on site inspections. The original deficiency is listed below:
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 clients status at discharge in one of two client records reviewed.
The findings included:
A plan of correction follow up inspection was conducted on April 20, 2012. Nine client records were reviewed. Two client records represented clients who had been discharged from the facility. One of two client records included documentation of a discharge summary that was missing documentation of the client response to treatment and the client's status at discharge.
Client record # 9, with an admission date of 10/26/2011 and a discharge date of 1/9/12, included documentation of a discharge summary that did not include the client's response to treatment and the client's status at discharge.
This was reviewed with the Clinical Supervisor who did not dispute the findings.
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Plan of Correction
The Facility and Clinical Director shall meet with all clinical staff and conduct documentation training. Clinical staff shall be 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, the facility failed to document attempts to follow up on the client after discharge, in accordance with facility policy and procedure, in two of two client records reviewed.
The findings included:
A plan of correction follow up inspection was conducted on April 20, 2012. Nine client records were reviewed. Two client records represented clients who had been discharged from the facility. Two of two client records were required to include documentation of attempts to follow up on the client in accordance with facility procedure. Facility procedure requires that attempts to follow up on the client take place at 30, 60 and 90 days post discharge. There was no documentation in either client record of an attempt to follow up on the client.
Client record # 8, with an admission date of 11/30/11 and a discharge date of 2/22/12, failed to include documentation of attempts to follow up on the client on 3/22/12. There was no documentation of an attempt to follow up on the client as of 4/20/12.
Client record # 9, with an admission date of 10/26/2011 and a discharge date of 1/9/12, failed to include documentation of attempts to follow up on the client on 2/9/12, 3/9/12 and 4/9/12. There was no documentation of an attempt to follow up on the client as of 4/20/12.
This was reviewed with the Clinical Supervisor who did not dispute the findings.
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Plan of Correction
The Facility and Clinical Director shall meet with all clinical staff and conduct documentation training. Clinical staff shall be 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. |
709.14(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, 10 or more hours of service per week, in three of seven client records.
The findings included:
A plan of correction follow up inspection was conducted on April 20, 2012. Seven client records were reviewed. Ten or more hours of service were provided in a week in three of the seven client records. Services provided that consist of ten or more hours of service per week require a Partial Hospitalization license. The facility does not have a Partial Hospitalization license. 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 # 1- The client was admitted on 2/10/12 and last treated on 4/4/12. The record of service in this record revealed that services occurred at ten or more hours per week during the following weeks: 2/20/2012 through 2/22/2012; and 2/27/2012 through 2/29/2012.
Client record # 4 - The client was admitted on 1/27/12 and was last treated on 4/6/2012. The record of service in this record revealed that services occurred at ten or more hours per week during the following weeks: 4/2/2012 through 4/6/2012; and 3/5/2012 through 3/9/2012.
Client record # 5 - The client was admitted on 1/31/12 and was last treated on 4/4/2012. The record of service in this record revealed that services occurred at ten or more hours per week during the following weeks: 4/2/2012 through 4/4/2012.
This was reviewed with the Clinical Supervisor and the findings were not disputed.
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Plan of Correction
The program director and clinical director shall meet with clinical and non- clinical staff and reiterate with each of them the requirement 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. |