INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Men & Women For Human Excellence, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training in two of six personnel records.
The findings include:
On March 24, 2011, six personnel records were reviewed for documentation of 6 hours of HIV/AIDS training and 4 hours of TB/STD training. The facility did not document 6 hours of HIV/AIDS training and 4 hours of TB/STD training in personnel records #4 and 8.
Personnel #4 and 8 were identified as counselors and required documentation of 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the first year of employment.
Personnel #4 was hired on February 1, 2010 and was due to complete 6 hours of HIV/AIDS and 4 hours of TB/STD training by February 1, 2011. There was no documentation in personnel #4 ' s record to verify HIV/AIDS and TB/STD training had been completed.
Personnel #8 was hired on February 17, 2010 and was due to complete 6 hours of HIV/AIDS and 4 hours of TB/STD training by February 17, 2011. There was no documentation in personnel #8 ' s record to verify HIV/AIDS and TB/STD training had been completed.
An interview with the facility director on March 24, 2011, confirmed that personnel records # 4 and 8 did not contain documentation of HIV/AIDS and TB/STD training.
This is a repeat citation.
The facility was cited on December 4, 2009, April 14, 2009, April 8, 2008, June 27, 2007, and April 3, 2007 for failing to ensure that staff persons and volunteers completed a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum.
In response to the citation issued on December 4, 2009, the facility's plan of correction submitted on 1/20/2010 and approved on 2/26/2010 stated the following:
"The Clinical Supervisor will review all staff records to ensure that clinical staff have the reqiured [sic] 6 six hours in TB/STD, HIV/AIDS training within one year of hire date for counselors and two years for non- counselors. Clinical Supervisor will also review staff records on a quarterly basis to ensure that trainings are completed "
In response to the citation issued on April 14, 2009, the facility's plan of correction submitted on 5/11/2009 and approved on 6/3/2009 stated the following:
"Clinical Director has contacted BEBASHI/Phildelphia [sic] Fight to facilitate training on HIV/AIDS and STD's for staff. BEBASHI has responded by agreeing to do the trainings by 7/1/09.
Clinical Director will ensure that all mandatory trainings are completed with in [sic] required time frame."
In response to the citation issued on April 8, 2008, the facility's plan of correction submitted on 4/24/2008 and approved on 5/16/2008 stated the following:
"Men & Women For Human Excellence's, Inc. (MWFHE)Clinical Director will ensure that all staff members is [sic] enrolled in TB/STD training by the date of June 10, 2008."
In response to the citation issued on June 27, 2007, the facility's plan of correction submitted on 6/29/2007 and approved on 7/5/2007 stated the following:
"All employees of Men & Women For Human Excellence, Inc. Drug and Alcohol outpatient program have been scheduled for HIV/AIDS as well as TB/STD tainings [sic] for September 17, 2007."
In response to the citation issued on April 3, 2007, the facility's plan of correction submitted on 5/1/2007 and approved on 5/23/2007 stated the following:
"The Clinical Director will review all staff required training on a quarterly period to ensure that all stafff [sic]have begun the process of meeting their yearly required training hours. The Clinical Director will also meet with each staff member to review and inform the staff of training hours that are still needed and required by the Department of Health Drug and Alcohol Licensing program within the upcoming year. The Clinical Director have begin reviewing all staff taining [sic] hours to ensure that staff members have began to meet required training hours for current year. This process will be completed by June 4, 2007."
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Plan of Correction
The Clinical Supervisor will ensure staff compliance with policy that states, "Staff persons and volunteers receiving a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment." With respect to personnel #4, said personnel is scheduled for HIV/AIDS education/training on June 15, 2011. Personnel #8 has submitted verification of having received 6 hours HIV/AIDS and 4 hours of tuberculosis, sexually transmitted diseases education/training; said verification has been placed in personnel #8 file. Also, in an effort to maintain compliance with the policy in question, the Clinical Supervisor and/or Office Manager will review all personnel files on a by-monthly basis in order to identify staff needing education/training prior to expiration date. |
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 the facility's Cardio Pulmonary Resuscitation (CPR) certification documents and an interview with the facility director, the facility failed ensure CPR certification and first aid training were provided to a sufficient number of staff persons, so that at least one person trained in these skills was onsite during the project's hours of operation.
The findings include:
On March 24, 2011, the facility's CPR certification documents were reviewed. The facility provided proof of CPR certification for only two staff members. The facility's posted hours of operation are 9:00 AM - 8:00 PM. The facility only produced proof of current CPR certification for two out of sixteen employees.
During the exit interview on March 24, 2011, the facility director confirmed that only two CPR certification documents were provided. The facility director stated additional staff members were CPR certified. The facility Director was given the opportunity to fax proof of the additional CPR certification the following day. As of April 14, 2011, no additional CPR certification documents were provided.
This is a repeat citation.
The facility was cited on December 4, 2009, April 14, 2009, April 3, 2007, and August 2, 2006 for failing to ensure that Cardio Pulmonary Resuscitation certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills was onsite during the project's hours of operation.
In response to the citation issued on December 4, 2009, the facility's plan of correction submitted on 1/20/2010 and approved on 2/26/2010 stated the following:
"The Clinical Supervisor will review all staff records to ensure that the appropriate number of staff are on site during operation hours with CPR and First Aid training. Also the Clinical Supervisor will continue to review staff records on a quartly [sic] basis to ensure that their [sic] is at least one staff person with CPR and First Aid training on site during operation hours."
In response to the citation issued on April 14, 2009, the facility's plan of correction submitted on 5/11/2009 and approved on 6/3/2009 stated the following:
"Clinical Director has acquired the training services of a Red Cross Certified Instructor to conduct First Aid and CPR Training to requisite staff by 7/1/09. Clinical Director is responsible for ensuring during hours of operation a certified staff member in CPR/First Aid will be present.
Clinical Director has also acquired the training services of a Certified Physician's Assistant to conduct training on Tuberculosis for the staff by 8/1/09."
In response to the citation issued on April 3, 2007, the facility's plan of correction submitted on 5/1/2007 and approved on 5/14/2007 stated the following:
"The Clinical Director of MWFHE, Inc. outpatient treatment program will review on a yearly basic all staff training requirements [sic] to ensure that MWFHE, INc. [sic] have enoug [sic] satff [sic] members with the required hours of trainings for CPR training. This process will ensure that all shifts will be covered with at least one staff person that has the required CPR and First Aid training as mandated by Department of Health Licensure."
In response to the citation issued on August 2, 2006, the facility's plan of correction submitted on 9/16/2006 and approved on 10/3/2006 stated the following:
"MWFHE, Inc. have sent [sic] up CPR and first aid trainings for all of its clinical staff members. During the month the Clinical Dirctor [sic], Administrative Assistance and clinical staff will be scheduled and attend CPR and First Aid trainings."
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Plan of Correction
The Clinical Supervisor and/or Office Manager will be responsible for ensuring that "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." Men & Women for Human Excellence believes at least 4 staff persons with the training in question shall be sufficient. Therefore, two additional staff persons will be scheduled to get CPR training within 90 days from the date of this POC submission. Additionally, the clinical supervisor and/or office manager will review staff personnel files on a bi-monthly basis to ensure that at least four (4) staff persons certified in CPR will always be part of the staff makeup. |
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 a review of the Staffing Requirements Facility Summary Report form completed by the facility on March 24, 2011 and an interview with the facility director, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
On March 23, 2011 and March 24, 2011 the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed six counselors, a clinical supervisor, project director and facility director as clinical staff. The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 37.5 hours per week.
Based the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week, and the total number of clients assigned to the following employees on March 23, 2011 and March 24, 2011, employee # 8 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients 'treatment by the facility's standard workweek.
The number of hours per week devoted by Employee # 8 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 37.5 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 8 had 36 active clients on March 23, 2011 and March 24, 2011.
Employee # 8 (37.5/37.5 = 1 FTE 36 clients/1 FTE = 36:1 caseload)
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Plan of Correction
The Clinical Supervisor and Office Manager will ensure that Men & Women for Human
Excellence remain in compliance with, "FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients." With respect to employee #8, one active client has been removed from said employee's caseload to bring it within compliance. Additionally, the clinical supervisor and office manager will review the caseloads of each counselor on a weekly basis to ensure an accurate FTE. that remains within the limits allowed.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document that fire extinguisher training was provided upon employment in three of four personnel records reviewed.
The findings include:
On March 24, 2011, the personnel records of four newly hire staff members were reviewed for documentation of fire extinguisher training. The facility did not document that fire extinguisher training was provided upon employment in personnel records # 2, 6 and 7.
Personnel #2 was hired on 7/26/10, but verification of this training was not documented at the time of review on 3/24/11.
Personnel #6 was hired on 10/4/10, but verification of this training was not documented until 10/29/10.
Personnel #7 was hired on 8/20/10, but verification of this training was not documented at the time of review on 3/24/11.
An interview with the facility director on 1/7/11, confirmed that personnel records #2, 6 and 7 did not contain documentation of fire extinguisher training provided upon employment.
This is a repeat citation.
The facility was cited on April 7, 2010, August 2, 2006 and April 22, 2005 for failing to document that fire extinguisher training was provided upon employment.
In response to the citation issued on April 7, 2010, the facility's plan of correction submitted on 5/23/2010 and approved on 6/01/2010, stated the following:
"MWFHE, Inc. Clinical Supervisor will ensure that all new hires complete the agency's extingusiher [sic] training within the seven day period upon hire."
In response to the citation issued on August 2, 2006, the facility's plan of correction submitted on 1/18/2007 and approved on 1/19/2007 stated the following:
"As stated in MWFHE, Inc. Policy and Procedure manual after each staff member have been familiarize and trained with the agency's fire emergency and evacuation plan he/she will sign proof of their understanding of the trainng [sic] and their understaning [sic] of their responsiblties [sic]."
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Plan of Correction
The Clinical Supervisor and/or Office Manager will be responsible for ensuring that new employees receive instruction in the use of the fire extinguisher upon employment. This instruction shall be documented by said persons. With respect to personnel #2 and #7, both employees have received the instruction as of 04/31/2011. Additionally, the personnel files of other staff persons have been reviewed to determine compliance and those indicating non-compliance have also received the instruction. The clinical supervisor and/or office manager will monitor orientation of new staff upon employment to ensure that fire extinguisher instructions are provided. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
On March 24, 2011, the personnel records of four newly hire staff members were reviewed for documentation of training to perform assigned tasks during emergencies. The facility did not document that this training was provided upon employment in personnel records # 2, 6 and 7.
Personnel #2 was hired on 7/26/10, but verification of this training was not documented at the time of review on 3/24/11.
Personnel #6 was hired on 10/4/10, but verification of this training was not documented until 10/29/10.
Personnel #7 was hired on 8/20/10, but verification of this training was not documented at the time of review on 3/24/11.
An interview with the facility director on 3/24/11, confirmed that personnel records # 2, 6 and 7 did not contain documentation of emergency training provided upon employment.
This is a repeat citation.
The facility was cited on April 7, 2010, August 2, 2006 and April 22, 2005 for failing to document emergency training.
In response to the citation issued on April 7, 2010, the facility's plan of correction submitted on 5/23/2010 and approved on 6/1/2010, stated the following:
" The Clinical Supervisor will ensure that all new hires complete the agency's emergency training within the first seven days of hire. "
In response to the citation issued on August 2, 2006, the facility's plan of correction submitted on 1/18/2007 and approved on 1/19/2007, stated the following:
"As stated in MWFHE, Inc. Policy and Procedure Manual, each staff member will trained on the correct procedure for emergencys [sic]. Upon the completion of the staff member trainning [sic] the individual will sign documentation the he/she understand and have compeleted [sic] their training."
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Plan of Correction
The Clinical Supervisor will "ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies." Such training shall be documented by said persons. With respect to personnel records #2, 6 and 7, training to perform assigned tasks during emergencies has now been provided. To maintain compliance with this regulation, the clinical supervisor and/or office manager will monitor adherence during orientation of new staff upon initial employment. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on the review of administrative documentation and an interview with the facility director, the facility failed to make available to the public an annual report.
The findings include:
On March 24, 2011, the facility ' s administrative records were reviewed for documentation of an annual report. The facility did not document an annual report for the 2009 year.
An interview with the facility director on March 24, 2011 confirmed that an annual report was not made available to the public.
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Plan of Correction
The Director of Clinical Services will meet with the CEO and the Executive Director of Men & Women for Human Excellence to ensure that the governing body documents an annual report and make such report available to the public. With respect to the annual report that is due for 2009, the clinical director has been informed that the report is still being compiled and will be forwarded when completed. Additionally, the director of clinical services will, quarterly, remind the governing body of the ongoing requirement of documenting and submitting an annual report to the public.
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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 administrative documentation and an interview with the facility director, the facility failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
On March 24, 2011, the facility's administrative records were reviewed for documentation of an annual audit of financial activities for the fiscal year ending December 31, 2009. The facility did not document a financial audit for the 2009 fiscal year.
An interview with the facility director on March 24, 2011 confirmed that an independent annual audit of financial activities had not been completed for the 2009 fiscal year ending December 31, 2009.
This is a repeat citation.
The facility was cited on September 7, 2010, April 7, 2010 and April 14, 2009, for failing to document an independent annual audit of financial activities for the fiscal years ending December 31, 2009, December 31, 2008 and December 2007.
In response to the citation issued on September 7, 2010, the facility's plan of correction submitted on 10/08/2010 and approved on 11/12/2010, stated the following:
"The Clinical Director will confer with the Executive Director and request that an independent annual audit of financial activities for the facility's January-December 2008 and/or December 2009 fiscal year be made available in time for the next Licensing Inspection. Upon completion of such documents, the Clinical Director will provide copies to Licensing Inspection for review. Also, an annual copy of an independent financial audits is to be completed and maintained by the Executive Director and will be made available upon request."
In response to the citation issued on April 7, 2010, the facility's plan of correction submitted on 5/23/2010 and approved on 6/1/2010, stated the following:
"The Project Director will address this issue to ensure that MWFHE, INc. [sic] have on-hand its independent annual audit of its financial activitites [sic] for review by The Department of Health. The Project Director will employ an independent auditing firm to perform MWFHE, INc. [sic] annual independent audit."
In response to the citation issued on April 14, 2009, the facility's plan of correction submitted on 5/11/2009 and approved on 6/9/2009, stated the following:
"Executive Director will be responsible to ensure that the Accountant provides an annual audit within a 6 month period from the end of Fiscal Year ending each 12/31."
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Plan of Correction
Men & Women for Human Excellence has retained the services of an independent certified public accountant to prepare an annual audit of Men & Women for Human Excellence financial activities for the fiscal year ending December 31, 2010. The Executive Director and the Director of Clinical Services has both been assured by the accountant that the financial audit would be completed by June 30, 2011. Once completed, the Director of Clinical Services shall ensure that a copy of the report is mailed to the Division of Drug and Alcohol Program Licensure by July 15, 2011. Also, to ensure that continue compliance of this standard is maintain, the Director of Clinical Services shall meet with the CEO and the Executive Director of Men & Women for Human Excellence on a quarterly basis to discuss this matter specifically. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, facility policy and procedures and an interview with the facility director, the facility failed to document a medical history within 30 days after the date of admission as per facility policy in five of six client records.
The findings include:
The facility's policy and procedures listed under C.2.c.d states the following:
"C. Admission Procedure (Initial Interview)
Admitting counselor shall perform the following procedures when admitting or declining admittance to potential clients. ...
2. Assessment Evaluation The following forms are to be completed, signed and dated by the intake counselor doing the initial evaluation. ...
c. Complete the PSYCHOSOCIAL Assessment or Comprehensive Biopsychosocial Evaluation (CBE) and note appropriateness via the DSM-IV criteria for psychoactive substances. If a prior evaluation has been completed by another licensed drug and alcohol agency within the last 60 days and is being obtained through signed release authorizations the counselor and client should focus on the at information and the dimensional criteria in the clinical interview. The review of any and all information forwarded from another agency will be documented in the client file. (30 days)
d. Complete the Assessment report resulting form the BIOPSYCHOSOCIAL or CBE data conclude with a Comprehensive Treatment Plan. This plan will include: (30 days)
Client Demographic Data,
Substance Abuse History
Family Genealogy
Family History and Dynamics
Relational History
Educational History
Employment History
Medical History
Treatment History
Medical
Psychiatric
Substance abuse
Goals
Conclusions
Recommendations and suggested treatment strategies
Signed and dated by Primary Counselor completing this report"
On March 24, 2011 six client records requiring medical histories were reviewed. The facility policy indicated that the medical history was to be completed within 30 days. The Facility Director stated their policy is to complete a medical history within 30 days after admission for all clients. The facility did not document a medical history within 30 days, as per facility policy, in client records # 1, 2, 3, 5 and 6.
The admission date for client #1 was 8/19/10, but the medical history was dated 9/27/10.
The admission date for client #2 was 9/22/10, but the medical history was not signed or dated.
The admission date for client #3 was 11/1/10, but the medical history was dated 12/15/10.
The admission date for client #5 was 4/28/10, but the medical history was dated 6/22/10.
The admission date for client #6 was 7/12/10, but the medical history was not signed or dated.
An interview with the facility director on March 24, 2011 confirmed the findings.
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Plan of Correction
The Director of Clinical Services and the Clinical Supervisor have met and will continue to meet with clinical staff to reinforce the policy that states "biopsychosocial histories should be completed within 30 days from date of admission." All client charts will be reviewed on a bi-weekly basis; this will enable the clinical supervisor to identify clients whose biopsychosocial (including medical history) is due "soon" or "immediately." |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a drug and alcohol history within 30 days after the date of admission in five of six client records.
The findings include:
On March 24, 2011 six client records requiring drug and alcohol histories were reviewed.
The facility's policy and procedures listed under C.2.c.d states the following:
"C. Admission Procedure (Initial Interview)
Admitting counselor shall perform the following procedures when admitting or declining admittance to potential clients. ...
2. Assessment Evaluation The following forms are to be completed, signed and dated by the intake counselor doing the initial evaluation. ...
c. Complete the PSYCHOSOCIAL Assessment or Comprehensive Biopsychosocial Evaluation (CBE) and note appropriateness via the DSM-IV criteria for psychoactive substances. If a prior evaluation has been completed by another licensed drug and alcohol agency within the last 60 days and is being obtained through signed release authorizations the counselor and client should focus on the at information and the dimensional criteria in the clinical interview. The review of any and all information forwarded from another agency will be documented in the client file. (30 days)
d. Complete the Assessment report resulting form the BIOPSYCHOSOCIAL or CBE data conclude with a Comprehensive Treatment Plan. This plan will include: (30 days)
Client Demographic Data,
Substance Abuse History
Family Genealogy
Family History and Dynamics
Relational History
Educational History
Employment History
Medical History
Treatment History
Medical
Psychiatric
Substance abuse
Goals
Conclusions
Recommendations and suggested treatment strategies
Signed and dated by Primary Counselor completing this report"
The facility director stated their policy is to complete a drug and alcohol history within 30 days after admission for all clients. The facility did not document a drug and alcohol history within 30 days, as per facility policy, in client records # 1, 2, 3, 5 and 6.
The admission date for client #1 was 8/19/10, but the drug and alcohol history was dated 9/27/10.
The admission date for client #2 was 9/22/10, but the drug and alcohol history was not signed or dated.
The admission date for client #3 was 11/1/10, but the drug and alcohol history was dated 12/15/10.
The admission date for client #5 was 4/28/10, but the drug and alcohol history was dated 6/22/10.
The admission date for client #6 was 7/12/10, but the drug and alcohol history was not signed or dated.
An interview with the facility director on March 24, 2011 confirmed the findings.
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Plan of Correction
The Director of Clinical Services and the Clinical Supervisor have met and will continue to meet with clinical staff to reinforce the policy that states "biopsychosocial histories should be completed within 30 days from date of admission." All client charts will be reviewed on a bi-weekly basis; this will enable the clinical supervisor to identify clients whose biopsychosocial (including drug and alcohol history) is due soon or immediately. |
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 and an interview with the facility director, the facility failed to document a personal history within 30 days after the date of admission in five of six client records.
The findings include:
On March 24, 2011 six client records requiring personal histories were reviewed.
The facility's policy and procedures listed under C.2.c.d states the following:
"C. Admission Procedure (Initial Interview)
Admitting counselor shall perform the following procedures when admitting or declining admittance to potential clients. ...
2. Assessment Evaluation The following forms are to be completed, signed and dated by the intake counselor doing the initial evaluation. ...
c. Complete the PSYCHOSOCIAL Assessment or Comprehensive Biopsychosocial Evaluation (CBE) and note appropriateness via the DSM-IV criteria for psychoactive substances. If a prior evaluation has been completed by another licensed drug and alcohol agency within the last 60 days and is being obtained through signed release authorizations the counselor and client should focus on the at information and the dimensional criteria in the clinical interview. The review of any and all information forwarded from another agency will be documented in the client file. (30 days)
d. Complete the Assessment report resulting form the BIOPSYCHOSOCIAL or CBE data conclude with a Comprehensive Treatment Plan. This plan will include: (30 days)
Client Demographic Data,
Substance Abuse History
Family Genealogy
Family History and Dynamics
Relational History
Educational History
Employment History
Medical History
Treatment History
Medical
Psychiatric
Substance abuse
Goals
Conclusions
Recommendations and suggested treatment strategies
Signed and dated by Primary Counselor completing this report"
The facility director stated their policy is to complete a personal history within 30 days after admission for all clients. The facility did not document a personal history within 30 days, as per facility policy, in client records # 1, 2, 3, 5 and 6.
The admission date for client #1 was 8/19/10, but the personal history was dated 9/27/10.
The admission date for client #2 was 9/22/10, but the personal history was not signed or dated.
The admission date for client #3 was 11/1/10, but the personal history was dated 12/15/10.
The admission date for client #5 was 4/28/10, but the personal history was dated 6/22/10.
The admission date for client #6 was 7/12/10, but the personal history was not signed or dated.
An interview with the facility director on March 24, 2011 confirmed the findings.
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Plan of Correction
The Director of Clinical Services and the Clinical Supervisor have met and will continue to meet with clinical staff to reinforce the policy that states "biopsychosocial histories should be completed within 30 days from date of admission." All client charts will be reviewed on a bi-weekly basis; this will enable the clinical supervisor to identify clients whose biopsychosocial (including personal history) is due soon or immediately. |
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 and an interview with facility director, the facility failed to document psychosocial evaluations to include an assessment of the client's assets/strengths, coping mechanisms, negative factors that might inhibit treatment, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude toward and ability to participate in the treatment process in six of six client records reviewed.
The findings include:
On March 24, 2011 six client records requiring psychosocial evaluations were reviewed, specifically, records # 1, 2, 3, 4, 5 and 6. The facility failed to document the client's assets/strengths, coping mechanisms, negative factors that might inhibit treatment, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client ' s attitude toward and ability to participate in the treatment process in client records #1, 2, 3, 4, 5 and 6.
The psychosocial evaluation in client record #1, dated 9/27/10 did not include assets/strengths, coping mechanisms, negative factors that might inhibit treatment, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The psychosocial evaluation in client record #2 was not signed or dated and did not include assets/strengths, coping mechanisms, negative factors that might inhibit treatment, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The psychosocial evaluation in client record #3, dated 12/15/10 did not include assets/strengths, coping mechanisms, negative factors that might inhibit treatment, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The psychosocial evaluation in client record #4, dated 4/14/10 did not include assets/strengths, coping mechanisms, negative factors that might inhibit treatment, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The psychosocial evaluation in client record #5, dated 6/22/10 did not include assets/strengths, coping mechanisms, negative factors that might inhibit treatment, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The psychosocial evaluation in client record #6 was not signed or dated and did not include assets/strengths, coping mechanisms, negative factors that might inhibit treatment, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
An interview with the facility director on March 24, 2011 confirmed the findings.
This is a repeat citation.
The facility was cited on September 7, 2010, April 7, 2010, December 4, 2009, April 14, 2009, April 8, 2008, April 3, 2007 and August 2, 2006 for failing to document psychosocial evaluations to include a composite picture of the individual in relationship to the collected historical information
In response to the citation issued on September 7, 2010, the facility's plan of correction submitted on 10/08/2010 and approved on 11/12/2010, stated the following:
"The Clinical Director will review, with all clinical staff, the facility's policy that requires a psychosocial evaluation to be completed within 30 days after admission for all clients. All such reviews are to be documented. Compliance of this policy will be monitored via bi-weekly chart audits, by the Clinical Supervisor. If psychosocial evaluations have not been completed by the 23rd day, the primary therapist will be alerted and instructed to complete it within the following six days at which time the clinical supervisor will audit the identified chart again. If the psychosocial is not completed by day 29, the clinical supervisor will direct the primary therapist, assigned to the case, to complete it. The clinical supervisor is to report non-compliance of this policy to the clinical director for review and possibly further action if warranted. Also, the Clinical Director will provide mandatory trainings for all clinical staff on the appropriate method of completing psychosocial evaluations. Trainings will take place during weekly scheduled staff meetings. The Clinical Supervisor will be responsible for conducting bi-weekly chart reviews to determine if newly acquired knowledge is being applied. In client records # 1, 2, 3, 4 and 5, psychosocial evaluations have been completed. In client records # 6, 7, and 8, dates and signatures has been affixed to the psychosocial evaluations. Additionally, the psychosocial evaluations now provide a composite picture of the individuals in relationship to the collected historical information. In client record # 9, a psychosocial evaluation has been completed and now provides a composite picture of the individual in relationship to the collected historical information. In client records # 10 and 11, the dates and signatures are now affixed to the psychosocial evaluations. Additionally, the psychosocial evaluations now provide a composite picture of the individuals in relationship to the collected historical information."
In response to the citation issued on April 7, 2010, the facility's plan of correction submitted on 5/23/2010 and approved on 6/1/2010, stated the following:
"MWFHE, Inc. will began [sic] training with its staff on psychosocial evaluations. Within the training MWFHE, Inc. will address how to document in its psychosocial evaluations, client's needs and problems, assets/strengths, coping mechanisms, potential or available support and attitude toward and ability to participate in treatament [sic]. The Clinical Supervisor will conduct random chart audits on a monthly basis after the trainings have been completed to ensure that psychosocial evaluations are completed proplerly [sic]."
In response to the citation issued on December 4, 2009, the facility's plan of correction submitted on 1/20/2010 and approved on 1/27/2010, stated the following:
"Clinical Director directly oversees all Intake/Assessments to ensure that psychosocials are completed on each patient.
Clinical Director has increased 1:1 clinical supervision with Intake Specialist to ensure that all components of the document are captured during the session.
Clinical Director conducts ongoing training for the Intake Specialist specifically in the areas of : Developing a strength-based document; Denoting the patient strengths and limitations; Addressing factors that impede/affect treatment;[sic]Coping Strategies of the Patient.
All Inatke [sic] materials to include the biopsychosocial are inspected by the clinical director for completeness."
In response to the citation issued on April 14, 2009, the facility's plan of correction submitted on 5/11/09 and approved on 6/9/09, stated the following:
"Training will be conducted by the Behavioral Health Consultant on July, 10, 2009 during which time all clinical staff will be instructed on approriate [sic] clinical information gathering. Clinical Director will ensure that training is conducted on July 10, 2009, and that all clinical staff is present.
Charts will be audited once a month by the Clinical Supervisor to ensure that the pscyhosocial document is completed, signed-off, and placed in consumer's chart ."
In response to the citation issued on April 8, 2008, the facility's plan of correction submitted on 4/28/2008 and approved on 5/5/2008, stated the following:
"The clinical supervisor will review clients [sic] records on a monthly period to ensure that psychosocial evaluations are completed within the timeframe period. The clinical director will also conduct trainings to ensure that all clinical staff have a understanding of how to complete psychosocial evaluations and how to idenfy [sic] assessment needs such as assets/strengths, support systems, coping mechanisms."
In response to the citation issued on April 3, 2007, the facility's plan of correction submitted on 5/01/2007 and approved on 5/23/2007, stated the following:
"The Clinical Director/Supervisor will review clients charts that may have deficienices [sic] pertaining to psychosocial evaluations, upon review the clinical director/supervisor will meet with counselor to address any deficienices [sic] for corrections. Furthermore the Clinical Director/ Supervisor will review all clinical notes and forms to ensure that counselors provide clear and clinical documentation on all client's [sic]. MWFHE will provide in-house and outside trainings for clinical staff concerning the deveolpment [sic] of psychosocial evaluations. These trainings will be in place by June 4, 2007. "
In response to the citation issued on August 2, 2006, the facility's plan of correction submitted on 9/16/2006 and approved on 10/3/2006, stated the following:
"The Clinical Director will be responsible for training and monitoring staff record for on-going compliance. The clinical evaluation has been revised. A clinical narrative will be completed based off the clinician's observation and assessment of what he/she depicts is happening during the assessment. Non-verbal cues will be monitored more closely as well as the vagueness of information given by the client. The clinician will be responsible for asking more open ended questions as well as doing more probing to get more than a generalized response from the client."
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Plan of Correction
The Director of Clinical Services and the Clinical Supervisor have met with and will continue to meet with clinical staff to reinforce appropriate methods of completing psychosocial evaluations. Also, the clinical director and the clinical supervisor will ensure that the facility document psychosocial evaluations to include an assessment of the client's assets/strengths, coping mechanisms, negative factors that might inhibit treatment, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude toward and ability to participate in the treatment process. Clinical director and clinical supervisor will reinforce with staff that evaluations must be signed and appropriately dated. With respect to client #1, the psychosocial evaluations now includes an assessment of the client's assets/strengths, coping mechanisms, negative factors that might inhibit treatment, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude toward and ability to participate in the treatment process and is appropriately signed and dated; client #2, the psychosocial evaluation now includes an assessment of the client's assets/strengths, coping mechanisms, negative factors that might inhibit treatment, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude toward and ability to participate in the treatment process and is appropriately signed and dated; client #3, the psychosocial evaluation now includes an assessment of the client's assets/strengths, coping mechanisms, negative factors that might inhibit treatment, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude toward and ability to participate in the treatment process and is appropriately signed and dated; client #4, the psychosocial evaluation now includes an assessment of the client's assets/strengths, coping mechanisms, negative factors that might inhibit treatment, conclusions regarding the client's appearance, behavior and reactions during the intake process, and conclusions regarding the client's attitude toward and ability to participate in the treatment process and is appropriately signed and dated; clients #5 and 6 are discharges therefore their evaluations remain the same. The clinical supervisor will conduct bi-weekly chart audits to determine compliance with policy relating to psychosocial evaluation documentation. |
709.92(a) 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:
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a treatment plan within 30 days after the date of admission in three of six client records.
The findings include:
On March 24, 2011, six client records requiring treatment plans were reviewed.
The facility's policy and procedures listed under D.1 states the following:
"D. Treatment Planning (Initial Plan First Session/Comprehensive and Updates ea. 30 - 60 days) ...
1. All Clients who are admitted to the Program will have a Comprehensive Treatment plan developed within 30 days."
The facility director stated their policy is to complete a treatment plan within 30 days after admission for all clients. The facility did not document a treatment plan within 30 days, as per facility policy, in client records # 1, 3 and 5.
The admission date for client #1 was 8/19/10, but the treatment plan was dated 10/4/10.
The admission date for client #3 was 11/1/10, but the treatment plan was dated 12/15/10.
The admission date for client #5 was 4/28/10, but the treatment plan was dated 6/22/10.
An interview with the facility director on March 24, 2011 confirmed the findings.
This is a repeat citation.
The facility was cited on September 7, 2010 for failing to document a treatment plan within 30 days after admission.
In response to the citation issued on September 7, 2010, the facility's plan of correction submitted on 10/11/2010 and approved on 11/12/2010 stated the following:
The Clinical Director has met with the clinical supervisor and the primary therapists assigned to client records # 2, 3, 4, 5, 9, 10, and 11 and instructed each therapist to complete the treatment plans that are past due during their next session with identified clients. The Clinical Director and Clinical Supervisor will audit the identified charts, bi-weekly, to ensure and confirm compliance. Also, the Clinical Director will review policy, during weekly staff meetings, with all clinical staff about completing treatment plans in a timely manner. Such review and/or training shall be documented. The Clinical Supervisor will conduct bi-weekly chart audits to ensure ongoing compliance.
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Plan of Correction
The Clinical Supervisor will ensure that "an individual comprehensive treatment and rehabilitation plan shall be developed with each client within 30 days upon completion of the initial treatment plan which is due on the day of admission." The Clinical Supervisor will audit client charts on a bi-weekly basis and document findings. Copies of such audits are to be provided to the Director of Clinical Services for review until evidence of compliance is confirmed. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a treatment plan update to include an assessment of the client ' s progress, as per facility policy, in six of six client records.
The findings include:
On March 24, 2011, six client records requiring treatment plan updates were reviewed, specifically, records # 1, 2, 3, 4, 5 and 6. The treatment plan updates did not include an assessment of progress, as per facility policy, in client records #1, 2, 3, 4, 5 and 6.
The facility's policy titled "Treatment Planning" states:
"Outpatient Treatment Plans will be reviewed and updated, by the client's primary counselor, every sixty days following the development of the previous treatment plan.
If the client was admitted to the Intensive Outpatient Program, the treatment plan will be updated every thirty days from the date of the initial treatment plan.
These reviews/updates are noted on the Treatment Plan Review/Update Form. Information regarding progress in areas or concerns is noted on the forms."
In client record #1, the treatment plan updates documented on 12/14/10 and 2/11/11 did not include an assessment of progress.
In client record #2, the treatment plan update documented on 2/13/11 did not include an assessment of progress.
In client record #3, the treatment plan update documented on 2/8/11 did not include an assessment of progress.
In client record #4, the treatment plan updates documented on 6/16/10, 8/11/10, 12/2/10, and 2/9/11 did not include an assessment of progress.
In client record #5, the treatment plan update documented on 7/24/10 did not include an assessment of progress.
In client record #6, the treatment plan update documented on 9/30/10 did not include an assessment of progress.
An interview with the facility director on March 24, 2011 confirmed the findings.
This is a repeat citation.
The facility was cited on April 7, 2010, April 14, 2009, April 4, 2008, June 27, 2007, April 3, 2007, and August 2, 2006 for failing to document treatment plan updates to include an assessment of progress.
In response to the citation issued on April 7, 2010, the facility provided the following plan of correction:
"MWFHE will began provide [sic] trainings for its staff on treatment planning. After the completions of the training the Clinical Supervisor will perform randon [sic] chart audits on a monthly basis to ensure that treatment plans are being completed on time."
In response to the citation issued on April 14, 2009, the facility's plan of correction submitted on 5/11/2009 and approved on 6/3/2009 stated the following:
"Clinical Director will incorporate in newly revised treatment plan a section requiring the stated progression or regression of the consumer in the treatment process as it pertains to established goals.
Training on the newly revised treatment plan was conducted on May 29, 2009 by a Behavioral Health Consultant. The Quality Assurance team will audit the chart once per month to ensure that this deficiency does not reoccur."
In response to the citation issued on April 8, 2008, the facility's plan of correction submitted on 4/29/2008 and approved on 5/5/2008 stated the following:
"The clinical supervisor will review client's record at least once per month to ensure that treatment plan updates are completed in the proper timeframe period. Also MWFHE will conduct on-site trainings with its clinical staff on treatment plan and updated treatment plans with the focus being on how to properly assess clients for updated treatment plan completion, example idenfing [sic] if a client has made progress or not with their individual goals, how to document moving clients to the next level of achieving their goals."
In response to the citation issued on June 27, 2007, the facility's plan of correction submitted on 7/2/2007 and approved on 7/9/2007 stated the following:
"The Clinical Supervisor will ensure that clinical staff complete updated treatment plans on time, sixty days after client's comprehensive treatment plans are completed. Clinical Supervisor will conduct trainnings [sic] on treatment plan updates during the month of August 2007, also the clincial [sic] supervisor will review client's records on a monthly basic [sic] to ensure continued compliance."
In response to the citation issued on April 3, 2007, the facility's plan of correction submitted on 5/1/2007 and approved on 5/23/2007 stated the following:
"MWFHE, Inc. Clinical Director/Supervisor will review treatment plan updates to ensure that counselor are working with clients towards goal accomplishments, such as addressing meeting goals. The Clinical Director /Supervisor will also meet with counselors to address deficiencies pertaining treatment plan updates. Any deficiencies [sic] found will be corrected [sic] by June 4, 2007. MWFHE, Inc. will continue to provide trainings for all clinical staff in regards to creating treatment plans. Trainings will be focus on helping staff in the areas of accomplishing treatment goals, and the reasoning for forming new goals for clients."
In response to the citation issued on August 2, 2006, the facility's plan of correction submitted on 9/16/2006 and approved on 10/3/2006 stated the following:
"The Clinical Director will be responsible for training and monitor staff records for ongoing compliance. MWFHE, Inc. have implemented a plan to do treatment plans for clients at least two (2) weeks before the due date to insure that the treatment plan is done prior to the expiration date. This proces [sic] will help with clients who are no-shows, absent or drop out at the time their individual treatment plan is due. The clinical Director will make sure that the treatment plan includes a reflection of the previous treatment plan as well as receive a verbal clinical reason from clinician as to why a new goal is being implemented before signing off on the treatment plan."
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Plan of Correction
The Clinical Supervisor will ensure that, "Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days" and include an assessment of the client's progress, as per facility policy. To confirm that this policy is complied with, the clinical supervisor will conduct bi-weekly chart audits and any chart identified as being in non-compliance will be addressed immediately. The clinical director and clinical supervisor has met with the primary therapist of client #1, 2, 3, 4, 5, and 6 to review the correct way to complete updated treatment plans. Said therapist verbalized increased understanding following the meeting. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of client records, and an interview with the facility director, the facility failed to document group progress notes to include a comment relative to each individual's response or participation in three of four records.
The findings include:
On March 24, 2011, four client records requiring group progress notes were reviewed, specifically, records # 1, 2, 3 and 4. The facility did not document group progress notes to include a comment relative to each individual's response or participation in client records # 1, 2 and 4.
In client record # 1 and 2, the progress notes documented on the following dates were identical and did not to include a comment relative to each individual's response or participation: 2/23/11, 2/16/11, 2/15/11, 2/9/11, 2/8/11, 2/7/11, 2/2/11, 1/31/11, 1/26/11, 1/25/11, 1/24/11, 1/19/11, 1/18/11, and 1/5/11.
In client records # 1, 2 and 4, the progress notes documented on the following dates were identical and did not to include a comment relative to each individual's response or participation: 2/16/11 and 1/31/11.
An interview with the facility director on March 24, 2011 confirmed the findings.
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Plan of Correction
The Clinical Supervisor will insure that "a complete client record on an individual which includes information relative to the client's involvement with the project" is placed in each client's chart. "Group progress notes are to include a comment relative to each individual's response or participation." With respect to client records #1, 2 and 4, the clinical supervisor has met with group facilitators to instruct each on the requirement of including a comment in the group progress note relative to each individual's response or participation. The clinical supervisor will randomly review the group progress notes of each group facilitator to confirm that each group progress note includes information relative to the client's involvement with the project. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On March 24, 2011 the facility was again found to be out of compliance with the following standards:
1.705.28(c)(4) Instruct staff in the use of fire extinguishers upon employment. This area of noncompliance was also identified during the April 7, 2010 (plan of correction submitted on 5/23/2010 and approved on 6/01/2010), August 2, 2006 (plan of correction submitted on 1/18/2007 and approved on 1/19/2007) and April 22, 2005 licensing inspections.
2.705.28(d)(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. This area of noncompliance was also identified during the April 7, 2010 (plan of correction submitted on 5/23/2010 and approved on 6/01/2010), August 2, 2006 (plan of correction submitted on 1/18/2007 and approved on 1/19/2007) and April 22, 2005 licensing inspections.
3.709.25 (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. This area of noncompliance was also identified during the September 7, 2010 (plan of correction submitted on 10/08/2010 and approved on 11/12/2010), April 7, 2010 (plan of correction submitted on 5/23/2010 and approved on 6/1/2010) and April 14, 2009 (plan of correction submitted on 5/11/2009 and approved on 6/9/2009) ,licensing inspections.
4.709.91(b)(6) Psychosocial evaluations. This area of noncompliance was also identified during the September 7, 2010 (plan of correction submitted on 10/08/2010 and approved on 11/12/2010), April 7, 2010 (plan of correction submitted on 5/23/2010 and approved on 6/1/2010), December 4, 2009 (plan of correction submitted on 1/20/2010 and approved on 1/27/2010), April 14, 2009 (plan of correction submitted on 5/11/09 and approved on 6/9/09), April 8, 2008 (plan of correction submitted on 4/28/2008 and approved on 5/5/2008), April 3, 2007 (plan of correction submitted on 5/1/2007 and approved on 5/23/2007) and August 2, 2006 (plan of correction submitted on 9/16/2006 and approved on 10/3/2006) licensing inspections.
5.709.92(a) An individual treatment and rehabilitation plan shall be developed with a client. This area of noncompliance was also identified during the September 7, 2010 (plan of correction submitted on 10/11/2010 and approved on 11/12/2010) licensing inspection.
6.709.92(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. This area of noncompliance was also identified during the April 7, 2010 (plan of correction submitted on 5/23/2010 and approved on 6/1/2010), April 14, 2009 (plan of correction submitted on 5/11/09 and approved on 6/9/09), April 8, 2008 (plan of correction submitted on 4/29/2008 and approved on 5/5/2008), June 27, 2007 (plan of correction submitted on 7/2/2007 and approved on 7/9/2007), April 3, 2007 (plan of correction submitted on 5/1/2007 and approved on 5/23/2007) and August 2, 2006 (plan of correction submitted on 9/16/2006 and approved on 10/3/2006) licensing inspections.
7.704.11(c)(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment. This area of noncompliance was also identified during the December 4, 2009 (plan of correction submitted on 1/20/2010 and approved on 1/26/2010), April 14, 2009 (plan of correction submitted on 5/11/09 and approved on 6/3/09), April 8, 2008 (plan of correction submitted on 4/24/2008 and approved on 5/16/2008), June 27, 2007 (plan of correction submitted on 6/29/2007 and approved on 7/5/2007), and April 3, 2007 (plan of correction submitted on 5/1/2007 and approved on 5/23/2007) licensing inspections.
8.704.11 (c)(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. This area of noncompliance was also identified during the December 4, 2009 (plan of correction submitted on 1/20/2010 and approved on 2/26/2010), April 14, 2009 (plan of correction submitted on 5/11/2009 and approved on 6/3/2009), April 3, 2007 (plan of correction submitted on 5/1/2007 and approved on 5/14/2007), and August 2, 2006 (plan of correction submitted on 9/16/2006 and approved on 10/3/2006) licensing inspections.
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Plan of Correction
The Executive Director and the Director of Clinical Services will work diligently to ensure that Men & Women for Human Excellence maintains compliance with plan(s) of correction submitted for standards: 705.28(c)(4) [Corrective Action Date: 04/11/2011], 705.28(d)(3)[Corrective Action Date: 05/01/2011], 709.25 (a)[Corrective Action Date: 07/15/2011], 709.91(b) (6)[Corrective Action Date: 05/18/2011], 709.92(a)[Corrective Action Date: 05/19/2011] , 709.92(b) [Corrective Action Date: 05/11/2011] 704.11(c)(1) [Corrective Action Date: 06/15/2011], 704.11(c)(2)[Corrective Action Date: 08/18/2011]. Also, Men & Women for Human Excellence will appropriately request Department approved extension(s) at the moment the need for such extension or modification of plans becomes apparent. With respect to repeat citations, Men & Women for Human Excellence shall provide ongoing trainings or schedule trainings for staff as well as providing continuous monitoring of those areas that requires ongoing attention in order to continue improving on our efforts to provide excellent client services while remaining compliant with Department standards. |