INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on November 13, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Men & Women for Human Excellence, Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors.
-An air conditioner unit in a group room did not have a front cover and was not in good repair.
-The front door to the large group room did not have an operable door knob.
-A ceiling tile in the middle group room is stained from an exterior leak.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The below repairs was completed by maintenance person on November 27, 2020
I. The air conditioner unit in the group room and was replaced and have a front cover;
II. The front door to the large group room knob was replace and is now operable.
III. Ceiling tile in the middle group room was replaced with new tiles.
MWFHE supervisor will ensure that the group room is inspected weekly by maintenance person for needed repairs then he/she will log repairs needed and completed weekly on the maintenance sheet. Supervisor will review maintenance binder weekly and initial |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide paper towels in the group room bathrooms and the mechanical dryers were inoperable.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The below repairs was completed by maintenance person on on November 27, 2020
1. The maintenance person restocked paper towels in the group room bathrooms and the mechanical dryers was removed.
MWFHE supervisor will ensure the maintenance person restock all supplies needed for the group room bathrooms including paper towels, toilet paper, liquid soap, ect.. The supervisor will review the daily maintenance sheet. The supervisor will initial maintenance once completed. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to provide ventilation in a bathroom located off the middle group room.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Programs Operations will ensure that a new ventilator will be installed in the bathroom located off the middle group room no later than Jan 20, 2020. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(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.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
Based on a review of the facility ' s financial information and discussion with the Facility Director, the facility failed to complete financial audits in accordance with their plan of correction approved by the Department from the May 21, 2020 licensing inspection. The facility failed to obtain the financial audit for 2017-2018 by June 30, 2020 as well as the 2018-2019 financial audit by October 31, 2020.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The CEO, received a draft copy of the 2017-2018 financial information from an independent auditor; once MWFHE received the final financial audit the director of programs operations will then forward a copy to DDAP no later then Jan 31, 2021;
The CEO will also obtain the 2018-2019 financial audit once the auditor company start working on it. The auditor company MWFHE use stated they could not give us a definite date as of when they will complete the 2018-2019 MWFHE Financial audit. The Auditor company is still working on finalizing (completing) MWFHE 2017-2018 financial report.
The Director of Programs Operation (DPO) will continue to obtain information from the auditor company concerning the 2018-2019 financial audit and when it will be completed. The DPO will then notify DDAP. If MWFHE can not meet the deadline of having the 2018-2019 audits completed by 5/1/2021 The PDO will notify DDAP to request an extension. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on five of seven client records reviewed, the facility failed assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client # 1 was admitted on July 2, 2020 and was still active at the time of the inspection. A treatment plan update dated October 27, 2020 indicated one individual session and three group sessions to occur weekly. There was no documentation of individual sessions the month of November and August, or the weeks of September 13-19, 20-26, 27-October 3, October 11-17, 18-24, 25-31, 2020.
Client # 2 was admitted on September 8, 2020 and was still active at the time of the inspection. A treatment plan update dated October 8, 2020 indicated one individual session and three group sessions to occur weekly. There was no documentation of individual sessions the weeks of September 13-19, 20-26, October 25-31, November 1-7, 8-14, 15-21, 2020.
Client # 3 was admitted on April 30, 2020 and was still active at the time of the inspection. A treatment plan update dated September 10, 2020 indicated one individual session and three group sessions to occur weekly. There was no documentation of individual sessions the months of August, September or October or the weeks of June 7-13, 21-27, May 3-9, 17-23, 2020. There was no documentation of group sessions November, October, September, August, and July. There were only two sessions documented the week of June 7-13 and no sessions the rest of June. There were only two session the week of May 3-9, 17-23, and 24-30, 2020.
Client # 4 was admitted on March 12, 2020 and was still active at the time of the inspection. A treatment plan update dated October 1, 2020 indicated one individual session and three group sessions to occur weekly. There was no documentation of individual sessions the months of March, April, May, and June. There were no individual sessions the weeks of June 28-July 4, July 5-11, 19-25, August 9-15, 16-22,23-29, September 6-12.
There are not three group sessions weekly the weeks of August 2-8, 9-15, 23-29, 30-September 5, September 13-19, 20-26, 28- October 3, 4-10, 11-17, 18-24, 25-31.
Client # 7 was admitted on January 17, 2019 and discharged on January 20, 2020. A treatment plan update dated December 3, 2019 indicated one individual session and three group sessions to occur weekly. There was no documentation of three group sessions occurring weekly the months of September, October, November, December, 2019 or January 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will ensure counseling services are provided according to the individual treatment and rehabilitation plan and documentation of an individual and group sessions services will be in all individual charts moving forward.
Clinical supervisor will audit individual charts weekly utilizing the audit sheet to ensure all clinical documents is in the chart for services provided. If during the audit the clinical supervisor find missing documentation then he/she will follow-up with the clinician to obtain missing notes, treatment plan, ect and then file in individual chart *this will ensure all notes are in chart). Next, he/she will sign/date the audit sheet confirming that the individual chart is in compliance. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on four of seven client records reviewed, the facility failed to document on the record of service counseling sessions provided in correlation with progress notes in the client record.
Client # 1 was admitted on July 2, 2020 and was still active at the time of the inspection. There was a progress note for counseling sessions in the client record for July 2, September 1, and October 27, 2020 but was not documented on the record of service.
Client # 2 was admitted on September 8, 2020 and was still active at the time of the inspection. There was a progress note for counseling sessions in the client record for October 5, 6, 7, 8, September 9, 14, 15, 21, 22, 29, 28, 2020 but was not documented on the record of service.
Client # 3 was admitted on April 30, 2020 and was still active at the time of the inspection. There was a progress note for counseling sessions in the client record for May 4, 18 and September 10, 2020 but was not documented on the record of service.
Client # 7 was admitted on January 17, 2019 and was discharged on January 24, 2020. There was a progress note for counseling sessions in the client record for December 17, 2019 but was not documented on the record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There have been staff shortages (Chart Room Clerk) at MWFHE during COVID-19 crisis. We do admit that we are behind in documenting/completing the record of service counseling sessions on the client record sheet in the chart. However, the 'Chart Room Clerk' attendance has improved and they have been working diligently to catch up on
documenting on the record of service counseling sessions in the client record. The clinical supervisor will review the record of service sheet during her weekly chart audit to ensure the record of services are documented/completed in the client chart. |