INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26, 2011 through July 28, 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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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 an interview with the facility director, the facility failed to make available to the public an annual report.
The findings include:
On July 26, 2011 the Licensing Specialist asked to see a copy of the facility's annual report for the 2009 year and a copy of the facility's annual report for the 2010 year. An annual report for the 2009 year and an annual report for the 2010 year were not presented for review.
An interview with the facility director conducted on July 26, 2011 at approximately 10:00 A.M. confirmed that the facility did not have an annual report for the 2009 year and an annual report for the 2010 year.
This is a repeat citation.
The facility was cited on March 24, 2011 for failing to make available to the public a copy of the facility's annual report.
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Plan of Correction
The governing body of Men & Women for Human Excellence shall make available to the public an annual report. The Chief Executive officer shall be responsible for completing the report and making such report upon request available to the public. Also, the CEO shall send information about the annual report to a local news paper for publication. State standards applicable to MWFHE shall be reviewed semi-annually by the Executive director and Clinical director who shall when necessary alert the CEO about the requirement for the timely submission of the annual report to the public. The CEO shall inform the Executive and Clinical directors when the report is completed and made ready for the public. A copy of report shall be forwarded to the state for confirmation of compliance. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records, the facility failed to provide documentation for the results of reference investigations for reference checks in two of five records reviewed.
The findings include:
On July 26, 2011 to July 27, 2011 five personnel records were reviewed for documentation of reference checks and I-9 forms. The facility did not provide documentation for the results of reference investigations in personnel records # 2 and 6.
Employee # 2 is the facility director and was hired July 26, 2010. However, personnel record # 2 did not include documentation of reference checks as of July 27, 2011.
Employee # 6 is a counselor and was hired March 16, 2011. However, personnel record # 6 did not include documentation of reference checks or an I-9 form as of July 27, 2011.
During ongoing dialogues with the facility director conducted on July 26, 2011 from approximately 2:00 P. M. to 3:30 P.M. and conducted on July 27, 2011 from approximately 11:00 A.M. to 11:30 A.M., the findings were confirmed.
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Plan of Correction
As of August 20, 2011, reference checks have been completed, documented and placed in personnel records #2, and 6. Also, I-9 forms have been completed and placed in personnel record #6. The office manager shall be responsible for maintaining personnel files and assuring that references and I-9 are obtained from potential employees prior to the first day of work. The Office Manager shall check references and I-9 forms , document the results of such checks and ensure that references and I-9 forms are placed in employees files. The Director of clinical services shall also be responsible for ensuring that references and I-9 forms are in personnel files by the timely review of each new employee's file. This process should ensure that the agency remain in full compliance with applicable Pennsylvania Department of Health standards. |
709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of salary information in five of seven records reviewed.
The findings include:
On July 26, 2011 to July 27, 2011 seven personnel records were reviewed for documentation of salary information. The facility did not provide documentation of salary information for personnel records # 1, 3, 4, 5, and 7.
The findings include:
On July 26, 2011 to July 27, 2011 seven records were reviewed for documentation of salary information. The facility did not provide documentation of salary information in personnel records # 1, 3, 4, 5, and 7.
Employee # 1 is the project director and was hired in November 2001. However, personnel record # 1 only included documentation of salary information for when employee # 1 was hired in November 2001.
Employee # 3 is the clinical supervisor and was hired on July 27, 2009. However, personnel record # 3 did not include documentation of salary information as of July 27, 2011.
Employee # 4 is a counselor and was hired on March 6, 2008. However, personnel record # 4 did not include documentation of salary information as of July 27, 2011.
Employee # 5 is a counselor and was hired on April 4, 2011. However, personnel record # 5 did not include documentation of salary information as of July 27, 2011.
Employee # 7 is a desk clerk and was hired on May 12, 2011. However, personnel record # 7 did not include documentation of salary information as of July 27, 2011.
During ongoing dialogues with the facility director conducted on July 26, 2011 from approximately 2:00 P.M. to 3:30 P.M. and conducted on July 27, 2011 from approximately 11:00 A.M. to 11:30 A.M., the Facility Director confirmed the findings.
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Plan of Correction
As of August 20, 2011, the current salary of all clinical and support staff has been documented and placed in their personnel files by the office manager; this includes records #1, 3, 4, 5, and 7. The office manager shall be responsible for maintaining personnel files and assuring that such files are in full compliance with the Penn Department of Health standards. Also, personnel files shall be inspected randomly on a regularly basis by appointed staff to confirm compliance. |
709.26(f)(1) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
(1) Job title.
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Observations
Based on a review of personnel records, the facility failed to provide written job descriptions for project positions in three of six records reviewed.
The findings include:
On July 26, 2011 to July 27, 2011 six personnel records were reviewed for documentation of job descriptions. The facility did not provide documentation of a job description in personnel records # 5, 6, and 7.
Employee # 5 is a counselor and was hired on April 4, 2011. However, personnel record # 5 did not include documentation of a job description.
Employee # 6 is a counselor and was hired on March 16, 2011. However, personnel record # 6 did not include documentation of a job description.
Employee # 7 is a counselor and was hired on May 12, 2011. However, personnel record # 7 did not include documentation of a job description.
During ongoing dialogues with the facility director conducted on July 26, 2011 from approximately 2:00 P.M. to 3:30 P.M. and conducted on July 27, 2011 from approximately 11:00 A.M. to 11:30 A.M., it was confirmed that personal records # 5, 6, and 7 did not include documentation of a job description.
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Plan of Correction
As of August 20, 2011, current job descriptions of all clinical and support staff, including those of personnel records # 5, 6, and 7, have been placed in the personnel files by the office manager The office manager shall be responsible for maintaining personnel files and assuring that such files are in full compliance with applicable Pennsylvania Department of Health standards. Also, personnel files shall be inspected randomly, on a regularly basis, by staff appointed by the clinical supervisor to confirm such compliance. The Clinical Director will meet with potential new employees to discuss among other things the description of the job being offerred at which time such document shall be given to the office manager. |
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 observations on July 28, 2011, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients and employees and visitors.
The findings include:
Because the facility's basement at the 2603 Cecil B. Moore location was being used to store vacuum cleaners, boxes, a computer, and other miscellaneous items, the facility was required
to make sure that the basement at the 2603 Cecil B. Moore location was in compliance with the regulation. Also, because the facility's basement at the 2600 Cecil B. Moore location was being used to store a table, chairs, shovels, and other miscellaneous items, the facility was required to make sure that the basement at the 2600 Cecil B. Moore location was in compliance with the regulation.
A physical plant inspection was conducted on July 28, 2011. During the inspection, at approximately 9:25 A.M. to 9:30 AM, it was observed that the exit leading to Cecil B. Moore street inside the basement at the facility's 2603 Cecil B. Moore building did not have any stairs. In addition, it was observed that this basement had areas of chipping paint on the brick walls, there were areas with electrical wiring and other wires that were hanging from the joists and light fixtures that were hanging from the ceiling. There were areas of the basement where the blue tarpaulins that were used as a vapor barrier to cover the dirt floor had been pulled back and revealed areas with standing water and/or moisture spots (near the furnace and the hot water tank). In addition, it was observed that were areas on the steps and staircase inside the basement at the 2603 Cecil B. Moore building that had cracked concrete.
Furthermore, during the inspection, at approximately 9:50 A.M. to 9:54 A.M., it was observed that inside the basement at the facility's 2600 Cecil B. Moore building had areas of unsecured wires, pipes, and outlets. Also, it was observed that inside the basement at the facility's 2600 Cecil B. Moore building there were areas had debris on the floor. In addition, it was observed that inside the basement at the facility's 2600 Cecil B. Moore building there were areas of the dirt floor that were wet.
During interviews with one of the counselors on July 28, 2011 at approximately 9: 32 A.M. and 9:55 A.M., the counselor confirmed the findings.
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Plan of Correction
The Chief Executive Officer will make arrangements for the installment of stairs leading to Cecil B. Moore Ave from inside the basement at that location. The maintenance crew chief will conduct monthly inspections to ensure that the stairs remain secure and in place. Also, the maintenance crew chief shall be responsible for removing chipped paint on the walls in the basement at the same location. The crew chief has corrected the problem of electrical wiring and other wires hanging from the joists and light fixtures hanging from the ceiling. In the areas of the basement where there was standing water and/or moisture spots (near the furnace and the hot water tank), the water has been removed and the floor has been dried. To determine the cause of this problem, the CEO shall retain the services of a contractor to assess the problem and also to assess and make recommendations for an ongoing resolution. Inside the basement at the facility's 2600 Cecil B. Moore Ave. building where unsecured wires, pipes, and outlets were noted, the maintenance crew chief has secured the wires, pipes, and outlets and shall conduct periodic inspections to assure that such wires, pipes, and outlets remain secure. Debris on the floor of the basement of this location has been removed by maintenance crew workers who are currently engaged in cleaning out and cleaning up the entire basement(s); this work is being supervised by the crew chief and completion of work shall be confirm by the Clinical Director. Inside the basement at the facility's 2600 Cecil B. Moore building there were areas of the dirt floor that were wet, these areas have been dried and an assessment will be done to determine the cause of the wetness. The results of the assessment shall determine the action to be taken. The CEO has assumed the responsibility for retaining someone to perform the assessment. Once this problem is corrected, weekly inspections of the plant will be conducted to ensure the problem remains resolved. Also, in the areas on the steps and staircase inside the basement at the 2603 Cecil B. Moore building that has cracked concrete, the CEO shall obtain the services of a contractor to assess the problem and make recommendations to correct the problem. |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on observations on July 28, 2011, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on July 28, 2011. During the inspection, at approximately 9:03 A.M., it was observed that the facility had several trash cans located outside in the rear of the building near the rear exit at the facility's 2603 W. Cecil B. Moore Avenue location. One of the trash cans was not covered with a lid.
During an interview with one of the counselors on July 28, 2011 at approximately 9:04 A.M., the counselor confirmed the findings.
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Plan of Correction
The maintenance crew chief shall conduct regular inspections of the building exterior and grounds. With respect to the trash container that did not have a lid, on August 19, at approximately 10 AM, a lid was obtained and placed on the trash container in question. The maintenance crew chief shall conduct or have someone conduct a daily inspection of the trash containers to insure that the applicable standard is fully complied with. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observations on July 28, 2011, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
The findings include:
Because the facility's basement at the 2603 Cecil B. Moore location was being used to store vacuum cleaners, boxes, a computer, and other miscellaneous items, the facility was required
to make sure that the basement at the 2603 Cecil B. Moore location was in compliance with the regulation. Also, because the facility's basement at the 2600 Cecil B. Moore location was being used to store a table, chairs, shovels, and other miscellaneous items, the facility was required to make sure that the basement at the 2600 Cecil B. Moore location was in compliance with the regulation.
A physical plant inspection was conducted on July 28, 2011. During the inspection, at approximately 9:25 A.M., it was observed that the exit door leading to Cecil B. Moore Street inside the basement at the facility's 2603 Cecil B. Moore location was locked. Also, during the inspection, at approximately 9:44 A.M. when the Licensing Specialist arrived at the front exit door on the first floor leading to the basement at the facility's 2600 Cecil B. Moore location, the front door was locked. In addition, during the inspection, at approximately 9:50 A.M., it was observed that the exit door leading to 26th Street inside the basement at the facility's 2600 Cecil B. Moore building was locked. After the Licensing Specialist, left the basement of 2600 Cecil B. Moore, the maintenance man at the facility re-locked the front exit door on the first floor leading to the basement.
During an interview with one of the counselors on July 28, 2011 at approximately 9:27 A.M., the counselor confirmed the findings.
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Plan of Correction
The maintenance crew chief shall unlock doors leading from the basement at both locations (2600 W Cecil B. Moore Ave and 2603 W. Cecil B. Moore Ave) to the street during normal operational hours and relock doors during non-operational hours. The maintenance crew chief will be responsible for unlocking both doors at the start of normal operational business hours and re-locking both doors at the end of normal operational business hours. The maintenance crew chief will conduct inspections, daily, to assure that doors remain unlock during normal operational hours and also to assure continued compliance with applicable regulations. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on observations on July 28, 2011 and an interview with one of the counselors, the facility failed to clearly indicate exits by the use of signs.
The findings include:
Because the facility's basement at the 2603 Cecil B. Moore location was being used to store vacuum cleaners, boxes, a computer, and other miscellaneous items, the facility was required
to make sure that the basement at the 2603 Cecil B. Moore location was in compliance with the regulation. Also, because the facility ' s basement at the 2600 Cecil B. Moore location was being used to store a table, chairs, shovels, and other miscellaneous items, the facility was required to make sure that the basement at the 2600 Cecil B. Moore location was in compliance with the regulation.
A physical plant inspection was conducted on July 28, 2011. During the inspection, at approximately 9:25 A.M., it was observed that the exit door leading to Cecil B. Moore Street inside the basement at the facility's 2603 Cecil B. Moore location did not have an exit sign posted. Also, during the inspection, at approximately 9:50 A.M., it was observed that the exit door leading to 26th Street inside the basement at the facility's 2600 Cecil B. Moore location did not have an exit sign posted.
During an interview with one of the counselors on July 28, 2011 at approximately 9:27 A.M., the counselor confirmed the findings.
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Plan of Correction
As of August 20, 2011, exit signs have been placed at the basement exits in the 2600 and 2603 Cecil
B. Moore Ave locations by the maintenance crew chief. The maintenance crew chief shall conduct regular inspections to assure that the signs remain in place.
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705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on observations on July 28, 2011, the facility failed to maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
The findings include:
Because the facility's basement at the 2600 Cecil B. Moore location was being used to store a table, chairs, shovels, and other miscellaneous items, the facility was required to make sure that the basement at the 2600 Cecil B. Moore location was in compliance with the regulation.
A physical plant inspection was conducted on July 28, 2011. During the inspection, at approximately 9:49 A.M., it was observed that the basement floor at the facility's 2600 Cecil B. Moore location did not have a smoke detector.
During an interview with one of the counselors on July 28, 2011 at approximately 9:55 A.M., the counselor confirmed the findings.
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Plan of Correction
On August 22, the maintenance crew chief installed one operable automatic smoke detector in the basement of the 2600 Cecil B. Moore Ave location and shall conduct monthly inspections to assure that smoke detector(s) are operable. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on observations on July 28, 2011, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
Because the facility's basement at the 2603 Cecil B. Moore location was being used to store vacuum cleaners, boxes, a computer, and other miscellaneous items, the facility was required
to make sure that the basement at the 2603 Cecil B. Moore location was in compliance with the regulation.
A physical plant inspection was conducted on July 28, 2011. During the inspection, at approximately 9:23 A.M., it was observed that the fire extinguisher in the basement at the facility's 2603 Cecil B. Moore location had not been inspected since March 2010. Also, from approximately 9:40 A.M. to 9:44 A.M., it was observed that the fire extinguisher in Group Room A at the facility's 2600 Cecil B. Moore location also had not been inspected since March 2010.
During an interview with one of the counselors on July 28, 2011 at approximately 9:24 A.M., the counselor confirmed the findings.
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Plan of Correction
The two fire extinguishers in question, one in the basement of 2603 Cecil B. Moore and the other located in group room A at 2600 W Cecil B Moore, were re-inspected on 9/14/11 by a Fire Protection Co. To ensure ongoing compliance with this standard, the maintenance crew will conduct monthly visual checks of all fire extinguishers on the premise to ensure that fire extinguishers have valid inspection tags. Such inspection shall be documented. |
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 a review of personnel records, the facility failed to document the instruction of staff in the use of the fire extinguishers upon staff employment in two of four personnel records reviewed.
The findings include:
On July 26, 2011 to July 27, 2011 four personnel records were reviewed for documentation of fire extinguisher training upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in two of four records reviewed, specifically personnel records # 6 and 7.
Employee # 6 is a counselor and was hired on March 16, 2011. However, personnel record # 6 did not include documentation of fire extinguisher training as of July 28, 2011.
Employee # 7 is a desk clerk and was hired on May 12, 2011. However, personnel record # 7 did not include documentation of fire extinguisher training as of July 28, 2011.
During ongoing dialogues with the facility director conducted on July 26, 2011 from approximately 2:00 P.M. to 3:30 P.M. and conducted on July 27, 2011 from approximately 11:00 A.M. to 11:30 A.M., it was confirmed that personal records # 6 and 7 did not include documentation of fire extinguisher training.
This is a repeat citation.
The facility was cited on March 24, 2011 and April 7, 2010.
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Plan of Correction
As of August 20, 2011, employees #6 and #7 had received fire extinguisher training provided by the agency. Such training has been documented and placed in the respected personnel files. The office manager shall be responsible for orienting new hires and scheduling each for mandatory trainings. The office manager has reviewed personnel files to determine wither or not all personnel have received the training. Personnel that did not have the training have now completed the training. Within the first week of hire, the clinical supervisor shall review personnel file to determine compliance with the standard. |
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 a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in two of four personnel records reviewed.
The findings include:
On July 26, 2011 to July 27, 2011, four personnel records were reviewed to verify that all personnel on all shifts had been trained to perform assigned tasks during emergencies. The facility failed to document the completion of emergency training in personnel records # 6 and 7.
Employee # 6 is a counselor and was hired on March 16, 2011. However, personnel record # 6 did not include documentation of emergency training as of July 28, 2011.
Employee # 7 is a desk clerk and was hired on May 12, 2011. However, personnel record # 7 did not include documentation of emergency training as of July 28, 2011.
During ongoing dialogues with the facility director conducted on July 26, 2011 from approximately 2:00 P.M. to 3:30 P.M. and conducted on July 27, 2011 from approximately 11:00 A.M. to 11:30 A.M., the Facility Director confirmed the findings,
This is a repeat citation.
The facility was cited on March 24, 2011 and April 7, 2010.
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Plan of Correction
As of August 20, 2011, employee #6 and #7 had received training provided by the agency to perform assigned tasks during emergencies and such training has been documented and placed in the respected personnel files. The office manager shall be responsible for maintaining personnel files and assuring that such files are in full compliance with applicable Pennsylvania Department of Health standards. Within 7 days of hire, the clinical director will review the files of new employees to confirm that new personnel had been trained to perform assigned tasks during emergencies. Personnel files shall be inspected randomly by the clinical supervisor on a bi-weekly basis to confirm full compliance. |
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, the facility failed to document a medical history in accordance with the facility's policy and procedures in two of eight records reviewed.
The findings include:
On July 27, 2011 through July 28, 2011, eight records were reviewed for documentation of a medical history. The facility did not document a medical history according to their policy and procedures in client records # 2 and 8. In addition, the facility did not complete a medical history in client records # 3 and 7.
The facility's policy listed under subject: "Management of Treatment and Rehabilitation" and subsection C.2. (d) states:
(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."
Client # 2 was admitted May 24, 2011; however, the medical history in client record # 2 did not include a date of completion as of July 28, 2011.
Client # 3 was admitted May 20, 2011; however, client record # 3 did not include documentation of a medical history as of July 28, 2011.
Client # 7 was admitted June 6, 2011; however, client record # 7 did not include documentation of a medical history as of July 28, 2011.
Client record # 8 was admitted June 7, 2011; however, the facility did not document the medical history for client # 8 until July 20, 2011.
During ongoing dialogues with the clinical supervisor conducted on July 27, 2011 from approximately 12:00 P.M. to 3:45 P.M. and on July 28, 2011 from approximately 12:00 P.M. to 4:15 P.M., it was confirmed that the facility did not document a medical history according to their policy and procedures in client records # 2 and 8. Also, during the same ongoing dialogues, it was confirmed that the facility did not document a medical history in client records # 3 and 7.
This is a repeat citation.
The facility was cited on March 24, 2011 for failing to document client medical histories.
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Plan of Correction
Men and Women for Human Excellence have hired a new Clinical Supervisor/Quality Assurance person who has assumed the responsibilities of auditing client's charts to assure that all client charts are in full compliance with applicable Pennsylvania Department of Health standards. With respect to client records: #2, a biopsychosocial medical history was completed on 6/15/11 by the primary therapist; with respect to client record #3, we are unable to complete a medical history because we have not been able to contact him and he will be discharge on 9/15/11; with respect to record #7, a drug and alcohol history was completed by primary therapist and placed in the chart; and client record #8 will retain the same date because we cannot go back into the record to change dates. The new Clinical Supervisor/Quality Assurance person is now responsible for conducting a review of new admission's biopsychosocial histories to assure that such histories are in full compliance with applicable Pennsylvania Department of Health standards. In instances where non-compliance is noted, the record shall be returned to the person responsible for the record in order to make required corrections. Subsequent to making corrections, the record will be returned to the clinical supervisor for further review and filing. Within three weeks of admission, the clinical supervisor is to review the record of new admissions to ensure compliance. |
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, the facility failed to document a drug or alcohol history in accordance with the facility's policy and procedures in four of eight records reviewed.
The findings include:
The facility's policy listed under subject: " Management of Treatment and Rehabilitation " and subsections C.2. (d), states:
(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 July 27, 2011 through July 28, 2011, eight records were reviewed for documentation of a drug or alcohol history.
The facility did not document a drug or alcohol history according to their policy and procedures in four of eight client records reviewed, # 2, 3, 7 and 8.
Client # 2 was admitted May 24, 2011; the drug or alcohol history in client record # 2 did not include a date of completion, the client's prior treatment, and the client's perception as of July 28, 2011.
Client # 3 was admitted May 20, 2011; however, client record # 3 did not include documentation of a drug or alcohol history as of July 28, 2011.
Client # 7 was admitted June 6, 2011; however, client record # 7 did not include documentation of a drug or alcohol history as of July 28, 2011.
Client # 8 was admitted June 7, 2011; however, the facility did not document the drug or alcohol history for client # 8 until July 20, 2011.
During ongoing dialogues with the clinical supervisor conducted on July 27, 2011 from approximately 12:00 P.M. to 3:45 P.M. and on July 28, 2011 from approximately 12:00 P.M. to 4:15 P.M., the Clinical Supervisor confirmed the findings.
This area of noncompliance was also identified during the March 24, 2011 (plan of correction submitted on 5/18/2011 and approved on 5/19/2011) licensing inspection.
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Plan of Correction
Men and Women for Human Excellence have hired a new Clinical Supervisor/Quality Assurance person who has assumed the responsibilities of auditing client's charts to assure that all client charts are in full compliance with applicable Pennsylvania Department of Health standards. With respect to client records: #2, a biopsychosocial drug and alcohol history, including the client's prior treatment, and the client's perception, was completed on 6/15/11 by primary therapist; with respect to client record #3, we are unable to complete this record because the client has not returned for treatment; he will be discharged on 9/15/11; with respect to client record #7, on, a drug and alcohol history was completed on 7/26/11 by the primary therapist and placed in the chart; client record #8 will retain the same date because we cannot go back into the record to change dates. The new Clinical Supervisor/Quality Assurance person is now responsible for conducting a review of new admissions biopsychosocial drug and alcohol histories to assure that such histories are in full compliance with applicable Pennsylvania Department of Health standards. In instances where non-compliance is noted, the record shall be returned to the person responsible for the record in order to make required corrections. Subsequent to making corrections, the record will be returned to the clinical supervisor for further review and filing if appropriate. Within three weeks of admission, the clinical supervisor shall review the record of new admissions to ensure full compliance. |
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 document a personal history in accordance with the facility's policy and procedures in two of eight records reviewed.
The findings include:
On July 27, 2011 through July 28, 2011, eight records were reviewed for documentation of a medical history. The facility did not document a personal history according to their policy and procedures in client records # 2, 3, 7 and 8.
The facility's policy listed under subject: "Management of Treatment and Rehabilitation" and subsections C.2. (d), states:
"(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."
Client # 2 was admitted May 24, 2011; the personal history in client record # 2 did not include a date of completion as of July 28, 2011. Also, the personal history in client record # 2 did not include the client's full legal history and documentation of the client's employment/vocation history as of July 28, 2011.
Client # 3 was admitted May 20, 2011; however, client record # 3 did not include documentation of a personal history as of July 28, 2011.
Client # 7 was admitted June 6, 2011; however, client record # 7 did not include documentation of a personal history as of July 28, 2011.
Client # 8 was admitted June 7, 2011; however, the facility did not document the personal history for client # 8 until July 20, 2011.
During ongoing dialogues with the clinical supervisor conducted on July 27, 2011 from approximately 12:00 P.M. to 3:45 P.M. and on July 28, 2011 from approximately 12:00 P.M. to 4:15 P.M., the Clinical Supervisor confirmed the findings.
This area of noncompliance was also identified during the March 24, 2011 (plan of correction submitted on 5/18/2011 and approved on 5/19/2011) licensing inspection.
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Plan of Correction
Men and Women for Human Excellence have hired a new Clinical Supervisor/Quality Assurance person who has assumed the responsibilities of auditing client's charts to assure that all client charts are in full compliance with applicable Pennsylvania Department of Health standards. With respect to client records: #2, on 8/4/11, a biopsychosocial Personal history, including the client's full legal history and documentation of the client's employment/vocation history, was completed by primary therapist; we are unable to complete the record of #3 because we have not seen her and she will be discharged on 9/15/2011; with respect to record #7, on 8/5/11 a Personal history was completed by primary therapist and placed in the chart; client record #8 will retain the same date because we cannot go back into the record to change dates. The new Clinical Supervisor/Quality Assurance person is now responsible for conducting a review of new admissions biopsychosocial Personal histories to assure that the completion of such histories are in full compliance with applicable Pennsylvania Department of Health standards. In instances where non-compliance is noted, the record shall be returned to the person responsible for the record in order to make required corrections. Subsequent to making corrections, the record will be returned to the clinical supervisor for further review and filing if deemed appropriate. Within three weeks of admission, the clinical supervisor shall review the record of new admissions to ensure full compliance. |
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 a psychosocial evaluation in accordance with the facility's policy and procedures and/or failed to document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanism, and/or attitude toward treatment.
The findings include:
The facility's policy listed under subject: "Management of Treatment and Rehabilitation" and subsections C.2. (d), states:
"(d) Complete the Assessment report resulting form the BIOPSYCHOSOCIAL or CBE data conclude with a Comprehensive Treatment Plan. This plan will include: (30 days)
On July 27, 2011 through July 28, 2011, eight records were reviewed for documentation of a psychosocial evaluation. The facility did not document a psychosocial evaluation in accordance with the facility's policy and procedures and/or failed to document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanism, and/or attitude toward treatment in six of eight client records reviewed, # 1, 2, 3, 5, 7 and 8.
Client # 1 was admitted May 20, 2011. The psychosocial evaluation was completed on June 8, 2011, but it did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and client ' s attitude toward treatment.
Client # 2 was admitted May 24, 2011; however, client record # 2 did not include documentation of a psychosocial evaluation.
Client # 3 was admitted May 20, 2011; however, client record # 3 did not include documentation of a psychosocial evaluation.
Client # 5 was admitted May 25, 2011. The psychosocial evaluation was completed on June 9, 2011, but it did not include an evaluation of the client ' s assets/strengths, support systems, and coping mechanism.
Client # 7 was admitted June 6, 2011; however, client record # 7 did not include documentation of a psychosocial evaluation.
Client # 8 was admitted June 7, 2011; however, the facility did not document the psychosocial evaluation until July 20, 2011. Also, the psychosocial evaluation did not include an evaluation of the client's coping mechanisms and attitude toward treatment.
During ongoing dialogues with the clinical supervisor conducted on July 27, 2011 from approximately 12:00 P.M. to 3:45 P.M. and on July 28, 2011 from approximately 12:00 P.M. to 4:15 P.M., the Clinical Supervisor confirmed the findings.
This area of noncompliance was also identified during the March 24, 2011 (plan of correction submitted on 5/18/2011 and approved on 5/19/2011) licensing inspection.
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Plan of Correction
Client # 1, a psychosocial evaluation that includes an evaluation of the client's assets/strengths, support systems, coping mechanisms, and client's attitude toward treatment has been completed by the primary therapist. Client #2 remains unchanged because we have not seen her and she is discharged as of 9/15/2011; Client #3 remains unchanged because we have not seen her and she is discharged as of 9/15/2011; Client #4, on 8/9/11, the primary counselor completed and documented a biopsychosocial evaluation for this client; client #5, on 8/11/11, the primary therapist of this client amended the evaluation to include an evaluation of the client's assets/strengths, support systems, and coping mechanism; client #7, this record will remain unchanged because we have not seen the client to complete/correct the record, this client is discharged as of 9/15/2011; client #8, on 8/10/11,the primary counselor amended the client's psychosocial evaluation to include an evaluation of the client's coping mechanisms and attitude toward treatment. Our new Clinical Supervisor/Quality Assurance person is now responsible for conducting a review of new admission's charts within 21 days of admission to assure that the evaluation is completed or near completionton and to assure that such documents are in full compliance with applicable Pennsylvania Department of Health standards. The clinical supervisor will meet with each of the aforementioned therapist to review standards for clarity |
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, the facility failed to document an individual treatment and rehabilitation plan in accordance with facility policy in five of eight records reviewed.
The findings include:
On July 27, 2011 through July 28, 2011, eight records were reviewed for documentation of an individual treatment and rehabilitation plan. The facility did not document an individual treatment and rehabilitation plan in accordance with facility policy in five of eight client records reviewed. # 2, 3, 4, 7, and 8.
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."
Client # 2 was admitted May 24, 2011; however, client record # 2 did not include documentation of an individual treatment and rehabilitation plan as of July 28, 2011.
Client # 3 was admitted May 20, 2011; however, client record # 3 did not include documentation of an individual treatment and rehabilitation plan as of July 28, 2011.
Client # 4 was admitted May 24, 2011; however, the facility did not document the individual treatment and rehabilitation plan for client # 4 until June 27, 2011.
Client # 7 was admitted June 6, 2011; however, client record # 7 did not include documentation of an individual treatment and rehabilitation plan as of July 28, 2011.
Client # 8 was admitted June 7, 2011; however, client record # 8 did not include documentation of an individual treatment and rehabilitation plan as of July 28, 2011.
During ongoing dialogues with the clinical supervisor conducted on July 27, 2011 from approximately 12:00 P.M. to 3:45 P.M. and on July 28, 2011 from approximately 12:00 P.M. to 4:15 P.M., the Clinical Supervisor confirmed the findings.
This area of noncompliance was also identified during the March 24, 2011 (plan of correction submitted on 5/18/2011 and approved on 5/19/2011) licensing inspection and the September 7, 2010 (plan of correction submitted on and approved on) follow-up inspection.
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Plan of Correction
Men and Women for Human Excellence have hired a new Clinical Supervisor/Quality Assurance person who has assumed the responsibilities of auditing client's charts and providing clinical supervision to assure that all client charts are in full compliance with applicable Pennsylvania Department of Health standards. With respect to client records # 2, # 3, # 7, and # 8, the respected primary counselors will in collaboration with each client develop and document an individual treatment and rehabilitation plan during their next individual session. With respect to client record # 4, the clinical supervisor will meet with the primary counselor of clinet record #4 and provide clarity about the standard applicable to the timeliness of completing and documenting individual treatment and rehabilitation plans. Also, the clinical supervisor will meet with the primary counselor of each of the aforementioned clients and review the standards applicable to the timely completion and documentation of individual treatment and rehabilitation plans. The Clinical Supervisor/Quality Assurance person is responsible and shall conduct regular reviews of client records to assure that such records, including individual treatment and rehabilitation plans, are in full compliance with applicable Pennsylvania Department of Health standards. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the frequency of treatment and rehabilitation services in one of four records reviewed.
The findings include:
On July 27, 2011 to July 28, 2011, four records were reviewed for documentation of frequency of treatment and rehabilitation services. The facility did not document the frequency of treatment and rehabilitation services in one of four client records reviewed, specifically, record # 4.
Client # 4 was admitted May 24, 2011. The individual treatment and rehabilitation plan was completed on June 27, 2011 and did not include documentation for the frequency of treatment and rehabilitation services as of July 28, 2011.
During ongoing dialogues with the clinical supervisor conducted on July 27, 2011 from approximately 12:00 P.M. to 3:45 P.M. and on July 28, 2011 from approximately 12:00 P.M. to 4:15 P.M.,the Clinical Supervisor confirmed the findings.
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Plan of Correction
As of August 26, 2011, deficiencies cited in Client record # 4 which include documentation for the frequency of treatment and rehabilitation services has been completed by the primary counselor. The Clinical Supervisor/Quality Assurance person is responsible for and shall conduct regular reviews of client records to assure that such records, including individual treatment and rehabilitation plans, are in full compliance with applicable Pennsylvania Department of Health standards.
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support service in the individual treatment and rehabilitation plan in three of four records reviewed.
The findings include:
On July 27, 2011 to July 28, 2011, four records were reviewed for documentation for the proposed type of support service in the individual treatment and rehabilitation plan. The facility did not document the proposed type of support service in the individual treatment and rehabilitation plan in three of four records reviewed, specifically, records # 4, 5, and 6.
Client # 4 was admitted May 24, 2011. The individual treatment and rehabilitation plan was completed on June 27, 2011 and did not include documentation for the proposed type of support service as of July 28, 2011.
Client # 5 was admitted May 25, 2011. The individual treatment and rehabilitation plan was completed on June 25, 2011 and did not include documentation for the proposed type of support service as of July 28, 2011.
Client # 6 was admitted May 24, 2011. The individual treatment and rehabilitation plan was completed on June 23, 2011 and did not include documentation for the proposed type of support service as of July 28, 2011.
During ongoing dialogues with the clinical supervisor conducted on July 27, 2011 from approximately 12:00 P.M. to 3:45 P.M. and on July 28, 2011 from approximately 12:00 P.M. to 4:15 P.M., the Clinical Supervisor confirmed the findings.
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Plan of Correction
As of August 26, 2011, deficiencies cited in Client records, # 4, 5, and 6, which include the failure to document the proposed type of support service in the individual treatment and rehabilitation plan has been corrected and documented by the primary counselor. The Clinical Supervisor/Quality Assurance person is responsible for and shall conduct regular reviews of client records to assure that such records, including individual treatment and rehabilitation plans, are in full compliance with applicable Pennsylvania Department of Health standards. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment and rehabilitation plan update in accordance with facility policy in six of six records reviewed.
The findings include:
On July 27, 2011 to July 28, 2011, six records were reviewed for documentation of a treatment and rehabilitation plan update. The facility did not document a treatment and rehabilitation plan update in client records # 1, 2, 3, 4, 5, and 6.
The facility's policy titled: "Management of Treatment and Rehabilitation," states:
" 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. "
Client # 1, an intensive outpatient client, was admitted May 20, 2011. The preliminary treatment plan was completed on May 20, 2011 and the individual treatment and rehabilitation plan was completed on June 8, 2011. However, client record # 1 did not include documentation of a treatment plan update as of July 28, 2011.
Client # 2, an intensive outpatient client, was admitted May 24, 2011. The preliminary treatment plan was completed on May 24, 2011. However, client record # 2 did not include documentation of an individual treatment and rehabilitation plan and a treatment plan update as of July 28, 2011.
Client # 3, an intensive outpatient client, was admitted May 20, 2011. The preliminary treatment plan was completed on May 20, 2011. However, client record # 3 did not include documentation of an individual treatment and rehabilitation plan and a treatment plan update as of July 28, 2011.
Client # 4, an intensive outpatient client, was admitted May 24, 2011. The preliminary treatment plan was completed on May 24, 2011 and the individual treatment and rehabilitation plan was completed on June 27, 2011. However, client record # 4 did not include documentation of a treatment plan update as of July 28, 2011.
Client # 5, an intensive outpatient client, was admitted May 25, 2011. The preliminary treatment plan was completed on May 25, 2011 and the individual treatment and rehabilitation plan was completed on June 25, 2011. However, client record # 5 did not include documentation of a treatment plan update as of July 28, 2011.
Client # 6, an intensive outpatient client, was admitted May 24, 2011. The preliminary treatment plan was completed on May 24, 2011 and the individual treatment and rehabilitation plan was completed on June 23, 2011. However, client record # 6 did not include documentation of a treatment plan update as of July 28, 2011.
During ongoing dialogues with the clinical supervisor conducted on July 27, 2011 from approximately 12:00 P.M. to 3:45 P.M. and on July 28, 2011 from approximately 12:00 P.M. to 4:15 P.M., the Clinical Supervisor confirmed the findings.
This area of noncompliance was also identified during the March 24, 2011 (plan of correction submitted on 5/19/2011 and approved on 5/20/2011), 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.
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Plan of Correction
Deficiencies cited in Client records # 1, 2, 3, 4, 5, and 6 with respect to facility's failure to document treatment and rehabilitation plan update every 30 days from date of the initial treatment plan, will be corrected during the next scheduled session with the primary counselors. Each client in collaboration with their primary counselor will develop an updated treatment plan. The clinical director has met with the counselors of the identified client records and has clarified facility's policy and state standard. Our recently hired Clinical Supervisor/Quality Assurance person is responsible for and shall conduct regular reviews of client records to assure that such records, including individual treatment and rehabilitation plans, are in full compliance with applicable Pennsylvania Department of Health standards. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in two of four records reviewed.
The findings include:
On July 27, 2011 through July 28, 2011, two records were reviewed to verify that counseling services are provided according to the individual treatment and rehabilitation plan. The facility did not provide counseling services according to the individual treatment and rehabilitation plan in client records # 5 and 6.
Client # 5 was admitted May 25, 2011. The individual treatment and rehabilitation plan was completed on June 25, 2011 and indicated that the client will receive individual and group sessions three times a week. However, client record # 5 only included documentation of individual progress notes on the following dates: 6/9/11 and 6/17/11 as of July 28, 2011. Also, client record # 5 only included documentation of group notes on the following dates: 5/27/11, 5/31/11, 6/1/11, 6/6/11, 6/7/11, 6/8/11, and 6/13/11 as of July 28, 2011.
Client # 6 was admitted May 24, 2011. The individual treatment and rehabilitation plan was completed on June 23, 2011 and indicated that the client will receive individual and group sessions three times a week. However, client record # 6 only included documentation of individual progress notes on the following dates: 5/27/11, 6/1/11, 6/3/11, 6/6/11, 6/8/11, 6/13/11, 6/14/11, 6/15/11, 6/20/11, 6/22/11, 6/23/11 6/27/11, 6/29/11/, 6/28/11, 7/5/11, 7/6/11, and 7/11/11 as of July 28, 2011.
During ongoing dialogues with the clinical supervisor conducted on July 27, 2011 from approximately 12:00 P.M. to 3:45 P.M. and on July 28, 2011 from approximately 12:00 P.M. to 4:15 P.M., the Clinical Supervisor confirmed the findings.
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Plan of Correction
Deficiencies cited in Client records # 5 and 6 with respect to the facility failure to provide counseling services according to the individual treatment and rehabilitation plan has been addressed. The clinical director has met with the clinical staff to clarify the standards that is applicable to the standards in question. Counselors will schedule clients for individual and group sessions according to the individual treatment and rehabilitation plan and document missed appointments. MWFHE has recently hired a new Clinical Supervisor/ Quality Assurance person who is responsible for and shall assure that counseling services are provided according to the individual treatment and rehabilitation plan. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on a review of client records, the facility failed to document medication records in three of six records reviewed.
The findings include:
On July 27, 2011 to July 28, 2011, six records were reviewed for documentation of medication records. The facility did not document a medication record in three of six client records reviewed, specifically, # 3, 6, and 7.
Client # 3 was admitted May 20, 2011; however, the client record # 3 did not include documentation of a mediation record as of July 28, 2011.
Client # 6 was admitted May 24, 2011; however, the client record # 6 did not include documentation of a mediation record as of July 28, 2011.
Client # 7 was admitted June 6, 2011; however, the client record # 7 did not include documentation of a mediation record as of July 28, 2011.
During ongoing dialogues with the clinical supervisor conducted on July 27, 2011 from approximately 12:00 P.M. to 3:45 P.M. and on July 28, 2011 from approximately 12:00 P.M. to 4:15 P.M., the Clinical Supervisor confirmed the findings.
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Plan of Correction
Deficiencies cited in Client records # 3, 6, and 7 with respect to the facility failure to document medication records have been corrected. The primary counselor of the aforementioned client records has amended the records so that medication documentation is accurately reflected. Our recently hired Clinical Supervisor/Quality Assurance person is responsible for and shall conduct regular reviews of client records to assure that such records, including the documentation of medication records, are in full compliance with applicable Pennsylvania Department of Health standards. |
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, the facility failed to document group progress notes to include a comment relative to each individual's response or participation in four of eight records reviewed.
The findings include:
On July 27, 2011 through July 28, 2011, eight records requiring group progress notes were reviewed. The facility did not document group notes to include a comment relative to each individual's response or participation in four of eight client records reviewed, specifically client records # 2, 5, 6, and 8.
Client # 2 was admitted May 24, 2011. The group notes were reviewed in client record # 2 from May 27, 2011 to June 22, 2011. The group progress notes documented on the following dates in client record # 1 did not include a comment relative to the each individual ' s response or participation: 5/31/11, 6/6/11, and 6/7/11.
Client # 5 was admitted May 25, 2011. The group notes were reviewed in client record # 5 from May 27, 2011 to June 13, 2011. The group progress notes documented on the following dates in client record # 5 did not include a comment relative to each individual ' s response or participation: 5/31/11, 6/1/11, 6/6/11, 6/7/11, 6/8/11, and 6/13/11.
Client # 6 was admitted May 24, 2011. The group notes were reviewed in client record # 6 from May 27, 2011 to July 6, 2011. The group progress notes documented on the following dates in client record # 6 did not include a comment relative to each individual ' s response or participation: 5/27/11, 6/1/11, 6/3/11, 6/6/11, 6/8/11, 6/13/11, 6/14/11, 6/15/11, 6/23/11, 6/27/11, 6/28/11, 6/29/11, 7/5/11, 7/6/11, and 7/6/11.
Client # 8 was admitted June 7, 2011. The group notes were reviewed in client record # 8 from June 3, 2011 to July 13, 2011. The group progress notes documented on the following dates in client record # 8 did not include a comment relative to each individual ' s response or participation: 6/20/11, 6/22/11, 6/27/11, 6/28/11, 6/29/11, 7/5/11, 7/6/11, 7/11/11, 7/12/11, and 7/13/11.
During ongoing dialogues with the clinical supervisor conducted on July 27, 2011 from approximately 12:00 P.M. to 3:45 P.M. and on July 28, 2011 from approximately 12:00 P.M. to 4:15 P.M., the Clinical Supervisor confirmed the findings.
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Plan of Correction
Our recently hired Clinical Supervisor/Quality Assurance person shall be responsible for and shall conduct regular reviews of client records to assure that there is a complete client record on each individual client which includes information relative to the client's involvement with the project. With respect to client records # 2, 5, 6, and 8, the Director of clinical services has met with group facilitators to clarify the Standard. Also, added to our group progress note form is a section specific for comment about the individual. It was stressed that a comment about the individual must be placed in that section. The clinical supervisor shall regularly review records to assure compliance. |
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 a review of client records and an interview with the clinical supervisor, the facility failed to document follow-up information in accordance with facility policy and procedures two of four records reviewed.
The findings include:
The facility's policy titled: "Management of Treatment and Rehabilitation, " states:
"It is the policy of Men and Women for Human Excellence Inc. to follow-up on all clients who have successfully or unsuccessfully completed the program. Follow-up occurs within 30, 60 and 90 days following discharge, by the Primary Counselor, and may be done through an individual session, follow-up phone conversation, or via client and/or family follow-up program evaluations. "
On July 27, 2011 through July 28, 2011, four records were reviewed for documentation of follow-up information. The facility did not document follow-up information in accordance with facility policy and procedures two of four records reviewed, specifically records #11 & 12..
Client # 11 was admitted August 24, 2010 and was discharged May 6, 2011; however, client record # 11 did not include documentation of follow-up information as of July 28, 2011.
Client # 12 was admitted December 24, 2010 and was discharged April 22, 2011; however, the facility did not document follow-up information for client # 12 until May 23, 2011.
During ongoing dialogues with the clinical supervisor conducted on July 27, 2011 from approximately 12:00 P.M. to 3:45 P.M. and on July 28, 2011 from approximately 12:00 P.M. to 4:15 P.M., the Clinical Supervisor confirmed the findings.
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Plan of Correction
The Clinical Director met with the clinical staff, including the primary counselors responsible for client records # 11 and # 12, and provided clarity with respect to the applicable standard regarding this citation. A follow-up has been completed and documented with respect to client record #11. The follow-up for client record #12 will stand, however staff has been advised to adhere to State and Agency policy. Our recently hired Clinical Supervisor/Quality Assurance person shall be responsible for and shall conduct regular reviews of client records to assure that there is a complete client record on each individual client which shall include the appropriate provision of follow-up at 30, 60, and 90 day intervals for all discharged consumers. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position of counselor.
The findings include:
On July 26, 2011 to July 27, 2011, three records were reviewed for documentation of the qualifications for the position of counselor. The facility failed to ensure that employee # 6 met the appropriate educational requirements for the position of counselor.
A review of the personnel record for employee # 6 indicated that the documentation for educational requirements for the position was insufficient. The documentation indicated that employee # 6 had three years of clinical experience; however, employee # 6 only had a Bachelor of Science in Business degree and did not have any degree or certification that met the educational requirement.
During ongoing dialogues with the facility director conducted on July 26, 2011 from approximately 2:00 P.M. to 3:30 P.M. and conducted on July 27, 2011 from approximately 11:00 A.M. to 11:30 A.M., it was confirmed that employee # 6 had three years of clinical experience but did not meet the educational requirements.
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Plan of Correction
Employee # 6 shall be given the position of counselor assistant and assigned to a full-time counselor for direct observation for 3 months and close supervision for 9 months until the educational requirements are fully met or until the criteria of becoming a counselor has been satisfied through appropriate supervision. In addition, we will monitor the employee's effort towards attaining an appropriate degree and achieving counselor status in five or less yeas. The office manager/personnel person and/or the Clinical Director shall conduct pre-employment reviews of all required documents to determine employment qualification prior to the start of the first work day for new hires. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an individual training plan for each employee when hired in two of two records reviewed of newly hired employees.
Also, based on a review of personnel records and an interview with the facility director, the facility failed to document an individual training plan for each existing employee in one of five records reviewed.
The findings include:
On July 26, 2011 to July 27, 2011, seven records were reviewed for documentation of individual training plans. The facility did not document an individual training plan of newly hired employees in personnel records # 5 and 7. Also, the facility did not document an individual training plan of existing employees in personnel record # 6.
Employee # 5 is a counselor and was hired on April 4, 2011; however, personnel record # 5 did not include documentation of an individual training plan as of July 27, 2011.
Employee # 6 is a counselor and was hired on March 16, 2011; however, personnel record # 6 did not include documentation of an individual training plan as of July 27, 2011.
Employee # 7 is a desk clerk and was hired on May 12, 2011; however, personnel record # 7 did not include documentation of an individual training plan as of July 27, 2011.
During ongoing dialogues with the facility director conducted on July 26, 2011 from approximately 2:00 P.M. to 3:30 P.M. and conducted on July 27, 2011 from approximately 11:00 A.M. to 11:30 A.M., it was confirmed that personnel records # 5, 6, and 7 did not include documentation of individual training plans.
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Plan of Correction
Individual training plans have been completed thru the collaborative efforts of the clinical supervisor and the personnel in question and placed in personnel records # 5, 6 and 7. The clinical supervisor shall be responsible for ensuring that newly hired employees receive an individual training plan within the first week of hire. Also, Our recently hired Clinical Supervisor/Quality Assurance person shall be responsible for and shall conduct regular reviews of personnel files to assure that the files are complete and in full compliance with applicable state regulations. |
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 a review of the personnel records and the facility's Staffing Requirements Facility Summary Report form, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS within the first year of employment for clinical staff and within two years of employment for non-clinical staff in one of six records reviewed.
On July 26, 2011 to July 2011, six records were for documentation of HIV/AIDS training. The facility failed to document 6 clock hours of HIV/AIDS training within two years of employment for non-clinical staff, specifically employee # 8.
Employee # 8, the Medical Director, who graduated medical school prior to the development of the curriculum for HIV/AIDS training, was hired April 14, 2009. However, employee # 8 did not complete HIV/AIDS training until June 11, 2011.
During ongoing dialogues with the facility director conducted on July 26, 2011 from approximately 2:00 P.M. to 3:30 P.M. and conducted on July 27, 2011 from approximately 11:00 A.M. to 11:30 A.M., it was confirmed that employee # 8 did not complete HIV/AIDS training until June 11, 2011.
This is a repeat citation.
The facility was cited on March 24, 2011, 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.
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Plan of Correction
Our recently hired Clinical Supervisor/Quality Assurance person shall be responsible for and shall conduct regular reviews of personnel files to assure that the files are complete and in full compliance with applicable state regulations. As such, it shall be the responsibility of the office manager and clinical supervisor to ensure that clinical personnel and non-clinical personnel obtain mandatory 6 hours of HIV/AIDS training within the appropriate time frame. Training may be part of personnel annual training plan. With respect to employee #8, he received HIV/AIDS training on June 11, 2011 and documentation of completing such training has been placed in his file. All staff shall be required to attend Mandatory HIV/AIDS trainings at BHTEN within the time period according to the State standard. Proof of completion of such training shall be in the form of "Certificate of Completion." The Office Manager shall be responsible for informing staff needing aforementioned trainings. |
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 personnel records, first aid cards and Cardio Pulmonary Resuscitation (CPR) certifications, the facility failed to ensure that a sufficient number of staff persons trained in first aid and CPR skills were present during the project's hours of operation.
The findings include:
On July 26, 27 & 28, 2011 the facility's personnel records and first aid cards and CPR certifications were reviewed. Only two of six counselors at the facility, the facility director, the intake specialist, and the office manager had documentation of current first aid and CPR certification. However, the facility director did not receive CPR certification until July 1, 2011 and did not receive first aid certification until July 6, 2011.
During the inspection, the Licensing Specialist asked to see the last four weeks of schedules for staff that were current in first aid and CPR certification. However, this information was not presented for review; therefore, there was no way to determine if the facility had a sufficient number of staff persons in first aid and CPR skills present during all the project's hours of operation.
This is a repeat citation.
The facility was cited on March 24, 2011, 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.
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Plan of Correction
Sufficient coverage was provided for the period of 6/28/11- 7/27/11. We will forward the work schedules for all staff for the period of 6/28/11 through 7/27/11 inclusive. We will also provide copies of first aid training certificates and CPR certification cards of staff that were certified at that time. |