INITIAL COMMENTS
|
This report is a result of an onsite follow-up inspection regarding the plans of correction for the July 28, 2011 licensure renewal inspection. The follow-up inspection was conducted on November 21-22, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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:
|
Plan of Correction
|
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
|
Observations
Based on observation during a physical plant inspection, the facility failed to maintain each stairway exceeding two steps with a well-secured handrail.
The findings include:
A physical plant inspection was conducted on November 22, 2011 between approximately 8:30 A.M. to 9:00 AM. The facility did not provide a handrail for the emergency exit in the basement of the 2600 Cecil B. Moore Avenue building. The basement's emergency exit stairway has more than two steps, but a handrail was not provided for these stairs.
The findings were confirmed by the facility's Director of Clinical Services on November 22, 2011.
|
Plan of Correction
A secure handrail was constructed.
The building maintenance supervisor will inspect the basement once a month to ensure that the deficiency does not occur and report to Program Director.
|
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.
|
Observations
Based on observation during a physical plant inspection, the facility failed install interconnected smoke detectors.
The findings include:
A physical plant inspection was conducted on November 22, 2011 between approximately 8:30 A.M. to 9:00 AM. At the time of inspection, the facility's smoke detector in the basement of their 2600 Cecil B. Moore Avenue building was battery operated and not hard wired to the smoke detectors on the first and second floors.
Because the facility's basement at the 2600 Cecil B. Moore Avenue location is being used to store various miscellaneous items, the facility is required ensure that it is in compliance with the licensing regulations.
The findings were confirmed by the facility's Director of Clinical Services on November 22, 2011.
This is a repeat citation.
The facility was cited on July 28, 2011 for failing to install smoke detectors.
|
Plan of Correction
Interconnected smoke detectors have since been installed.
The building maintenance supervisor will inspect the basement once a month to ensure that the deficiency does not occur and report to Program Director.
The Program Director will ensure that a certified fire protection company comes out to inspect and test the fire alarm system annually before the expiration date.
|
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
|
Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all fire extinguishers were wall mounted.
The findings include:
A physical plant inspection was conducted on November 22, 2011 between approximately 8:30 A.M. to 9:00 AM. At the time of inspection, the fire extinguisher in the basement of the 2600 Cecil B. Moore Avenue building was not wall mounted.
The findings were confirmed by the facility's Director of Clinical Services on November 22, 2011.
|
Plan of Correction
The fire extinguisher in the basement is now wall mounted.
The building maintenance supervisor will ensure that fire extinguishers remain wall mounted, are checked and updated once a year before the expiration dates.
The Program Director will ensure that a certified fire protection company comes out to inspect and test the fire alarm system annually before the expiration date.
|
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.
|
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.
The findings include:
On November 22, 2011, seven client records requiring documentation of medical histories were reviewed. The facility failed to document a medical history according to their policy and procedures in seven of seven records reviewed, client records # 1, 2, 3, 4, 5, 6 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 from 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 # 1 was admitted on 9/29/11. The medical history in client # 1's record did not include a counselor's dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
Client # 2 was admitted on 9/16/11, but client # 2's record did not contain a medical history at the time of review.
Client # 3 was admitted on 9/12/11. The medical history in client # 3's record did not include a counselor's dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
Client # 4 was admitted on 9/15/11. The medical history in client # 4's record did not include a counselor's dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
Client # 5 was admitted on 9/16/11, but client # 5's record did not contain a medical history at the time of review.
Client # 6 was admitted on 9/16/11. The medical history in client # 6's record did not include a counselor ' s dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
Client # 7 was admitted on 10/10/11. The medical history in client # 7's record did not include a counselor's dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
The findings were confirmed by the facility's Director of Clinical Services on November 22, 2011.
This is a repeat citation.
The facility was cited on March 24, 2011 and July 28, 2011 for failing to document client medical histories.
|
Plan of Correction
The Program Director with all clinical staff present conducted a documentation training. Clinical staff were instructed on clinical information gathering. They were instructed never to leave a blank space instead document that there is no history reported.
The Program Director and Clinical Director will conduct ongoing monthly documentation trainings. Counselors will be instructed on clinical information gathering.
The Clinical Director will ensure that all clinicians are present. The Clinical supervisor will audit records twice a month to ensure that the biopsychosocial document is appropriately completed.
|
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.
|
Observations
Based on a review of client records, the facility failed to document a drug and alcohol history in accordance with the facility's policy and procedures in seven of seven records reviewed.
The findings include:
On November 22, 2011, drug and alcohol histories in seven client records were reviewed, specifically records # 1, 2, 3, 4, 5, 6 and 7. The facility did not document a drug and alcohol history according to their policy and procedures in client records # 1, 2, 3, 4, 5, 6 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 from 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 # 1 was admitted on 9/29/11. The drug and alcohol history in client # 1's record did not include a counselor's dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
Client # 2 was admitted on 9/16/11, but client # 2's record did not contain a drug and alcohol history at the time of review.
Client # 3 was admitted on 9/12/11. The drug and alcohol history in client # 3's record did not include a counselor's dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
Client # 4 was admitted on 9/15/11. The drug and alcohol history in client # 4's record did not include a counselor's dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
Client # 5 was admitted on 9/16/11, but client # 5's record did not contain a drug and alcohol history at the time of review.
Client # 6 was admitted on 9/16/11. The personal history in client # 6's record did not include a dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
Client # 7 was admitted on 10/10/11. The drug and alcohol history in client # 7's record did not include a counselor's dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
The findings were confirmed by the facility's Director of Clinical Services on November 22, 2011.
This is a repeat citation.
The facility was cited on March 24, 2011 and July 28, 2011 for failing to document client drug and alcohol histories.
|
Plan of Correction
The Program Director with all clinical staff present conducted a documentation training. Collecting drug and alcohol histories was reviewed.
The Program Director and Clinical Director will conduct ongoing monthly documentation trainings. Counselors will be instructed on clinical information gathering.
The Clinical Director will ensure that all clinicians are present. The Clinical Supervisor will audit records twice per month to ensure that deficiencies do not recur in biopsychosocials.
|
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.
|
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 seven of seven records reviewed.
The findings include:
On November 22, 2011, personal histories in seven client records were reviewed, specifically records # 1, 2, 3, 4, 5, 6 and 7. The facility did not document a personal history according to their policy and procedures in client records # 1, 2, 3, 4, 5, 6 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 from 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 # 1 was admitted on 9/29/11. The personal history in client # 1's record did not include a counselor's dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
Client # 2 was admitted on 9/16/11, but client # 2's record did not contain a personal history at the time of review.
Client # 3 was admitted on 9/12/11. The personal history in client # 3's record did not include a counselor's dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
Client # 4 was admitted on 9/15/11. The personal history in client # 4's record did not include a counselor's dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
Client # 5 was admitted on 9/16/11, but client # 5's record did not contain a personal history at the time of review.
Client # 6 was admitted on 9/16/11. The personal history in client # 6's record did not include a counselor's dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
Client # 7 was admitted on 10/10/11. The drug and alcohol history in client # 7's record did not include a counselor's dated signature, so it was not possible to determine if the history had been completed within 30 days of admission.
The findings were confirmed by the facility's Director of Clinical Services on November 22, 2011.
This is a repeat citation.
The facility was cited on March 24, 2011 and July 28, 2011 for failing to document client personal histories.
|
Plan of Correction
The Program Director with all clinical staff present conducted a documentation training. Gathering personal history was reviewed.
The Program Director and Clinical Director will conduct ongoing monthly documentation trainings. Counselors will be instructed on clinical information gathering and case conceptualization.
The Clinical Director will ensure that all clinicians are present. The Clinical Supervisor will audit records twice per month to ensure that deficiencies do not recur in biopsychosocials.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
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 November 22, 2011, seven client records requiring psychosocial evaluations were reviewed. 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 in seven of seven client records reviewed, records # 1, 2, 3, 4, 5, 6 and 7.
Client # 1 was admitted on 9/29/11. The psychosocial evaluation in client # 1's record did not include the client's support systems, conclusions regarding the client's appearance and behavior during the initial interview, and conclusions regarding the client's attitude toward and ability to participate in the treatment process. Additionally, the psychosocial evaluation in client # 1's record did not include a counselor's dated signature, so it was not possible to determine if the evaluation had been completed within 30 days of admission.
Client # 2 was admitted on 9/16/11, but client # 2's record did not contain a psychosocial evaluation at the time of review.
Client # 3 was admitted on 9/12/11. The psychosocial evaluation in client # 3's record did not include the client's assets and strengths, support systems, coping mechanisms, conclusions regarding the client's appearance and behavior during the initial interview, and conclusions regarding the client's attitude toward and ability to participate in the treatment process. Additionally, the psychosocial evaluation in client # 3's record did not include a counselor's dated signature, so it was not possible to determine if the evaluation had been completed within 30 days of admission.
Client # 4 was admitted on 8/22/11. The psychosocial evaluation in client # 3's record dated 9/15/11 did not include the client's assets and strengths, support systems, coping mechanisms, conclusions regarding the client's appearance and behavior during the initial interview, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 5 was admitted on 9/16/11. The psychosocial evaluation in client # 5's record did not include the client's coping mechanisms. Additionally, the psychosocial evaluation in client # 5's record did not include a counselor's dated signature, so it was not possible to determine if the evaluation had been completed within 30 days of admission.
Client # 6 was admitted on 9/16/11. The psychosocial evaluation in client # 6's record did not include the client's coping mechanisms and conclusions regarding the client's appearance and behavior during the initial interview. Additionally, the psychosocial evaluation in client # 6's record did not include a counselor's dated signature, so it was not possible to determine if the evaluation had been completed within 30 days of admission.
Client # 7 was admitted on 10/10/11. The psychosocial evaluation in client # 7's record dated 11/10/11 did not include the client's assets and strengths, and coping mechanisms.
The findings were confirmed by the facility's Director of Clinical Services on November 22, 2011.
This is a repeat citation.
The facility was cited on July 28, 2011, March 24, 2011, September 7, 2010, April 7, 2010, December 4, 2009, April 14, 2009 and April 8, 2008 for failing to document psychosocial evaluations.
|
Plan of Correction
The Program Director with all counselors present conducted a documentation training. Clinicians were instructed to give their clinical impressions, their opinions and provide information why particular comments are made and also indicate how they got to the particular comments.
The Program Director and Clinical Supervisor will conduct ongoing monthly documentation trainings. Counselors will be instructed on clinical information gathering and case conceptualization.
The Clinical Director will ensure that all clinicians are present. The Clinical Supervisor will audit records twice per month to ensure that deficiencies do not recur in biopsychosocials.
|
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plans to include type and frequency of treatment and rehabilitation services in six of seven records reviewed.
The findings include:
On November 22, 2011, seven client records were reviewed for type and frequency of treatment and rehabilitation services, specifically records # 1, 2, 3, 4, 5, 6 and 7. The facility did not document treatment plans to include type and frequency of treatment and rehabilitation services in client records # 1, 2, 3, 5, 6 and 7.
Client # 1 was admitted on 9/29/11. The treatment plan in client # 1's record dated 10/28/11 did not include type and frequency of treatment and rehabilitation services.
Client # 2 was admitted on 9/16/11. The treatment plan in client # 2's record dated 10/16/11 did not include type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on 9/12/11. The treatment plan in client # 3's record dated 10/12/11 did not include type and frequency of treatment and rehabilitation services.
Client # 5 was admitted on 9/16/11. The treatment plan in client # 5's record dated 10/16/11 did not include type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on 9/16/11. The treatment plan in client # 6's record dated 10/14/11 did not include type and frequency of treatment and rehabilitation services.
Client # 7 was admitted on 10/10/11. The treatment plan in client # 7's record dated 11/10/11 did not include type and frequency of treatment and rehabilitation services.
The findings were confirmed by the facility ' s Director of Clinical Services on November 22, 2011.
This is a repeat citation.
The facility was cited on July 28, 2011, for failing to document treatment plans to include type and frequency of treatment and rehabilitation services.
|
Plan of Correction
The Clinical Director will develop and implement a new treatment plan form that will include the type and frequency of the sessions.
A newly developed treatment plan has been constructed. Information necessary to meet clinical standards has been incorporated in the new document.
The Clinical Director will
conduct training on the new form on December 29, 2011.
The Clinical Director will audit records twice per month to ensure that deficiencies do not recur in treatment plans.
|
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.
|
Observations
Based on a review of client records, the facility failed to document a record to include medication records. in two of three records reviewed.
The findings include:
On November 22, 2011, three client records requiring medication records were reviewed. The facility failed to document a complete medication record in two of three records reviewed, client records # 1 and 3.
Client # 1 was admitted 9/29/11. The treatment plan in client # 1's record dated 10/28/11 listed Trazadone 50 mg as the "prescribed medications monitored by staff psychiatrist" but the record did not document the frequency of use for this medication.
Client # 3 was admitted 9/12/11. The treatment plan in client # 3's record dated 10/12/11 listed Trazadone 100 mg as the " prescribed medications monitored by staff psychiatrist " but the record did not document the frequency of use for this medication.
The findings were confirmed by the facility's Director of Clinical Services on November 22, 2011.
This is a repeat citation.
The facility was cited on July 28, 2011, for failing to document medication records.
|
Plan of Correction
The Program Director with all counselors present conducted a documentation training. It was stressed that once a clinician mentions that a person in recovery is on medications, the name of the medication, the dosage and frequency should be documented.
The Program Director and Clinical Supervisor will conduct ongoing monthly documentation trainings. Counselors will be instructed on clinical information gathering.
The Clinical Director will ensure that all clinicians are present. The Clinical Supervisor will audit records twice per month to ensure that deficiencies do not recur in biopsychosocials.
|
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.
|
Observations
Based on a review of client records, the facility failed to document follow-up information in accordance with facility policy and procedures.
The findings include:
On November 22, 2011, six client records requiring follow-up information were reviewed. The facility failed to document follow-up information in accordance with their policy and procedures in two of six records reviewed, client records # 9 and 12.
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."
Client # 9 was admitted 5/26/11 and discharged 10/13/11, but client # 9's record did not contain documentation of follow-up information at the time of review.
Client # 12 was admitted 6/6/11 and discharged 10/7/11, but client # 12's record did not contain documentation of follow-up information at the time of review.
The findings were confirmed by the facility's Director of Clinical Services on November 22, 2011.
This is a repeat citation.
The facility was cited on July 28, 2011, for failing to document follow-up information.
|
Plan of Correction
The Program Director has purchased stamps which are kept by the Office Manager.
Once a week the Clinical Support Staff will look in the discharge follow-up book to see if a follow-up letter needs to be mailed out to any person who has been discharged within 30 days.
After mailing out the letter, the Clinical Support Staff will give a copy of the letter to Record Room staff for filing.
The Policy and Procedure manual will be amended to reflect the current procedure.
A list of discharged clients will be kept by the Office Manager and will be monitored weekly to ensure no client is overlooked or missed in the process.
The Office Manager will also provide supervision to Clinical support staff once every thirty days to discuss current procedures as well as the updating of the discharge follow-up book.
|