INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the July 28, 2011 licensure renewal inspection and for the November 22, 2011 plan of correction follow up inspection. The follow-up inspection was conducted on April 20, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Men & 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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709.26(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 ensure that a current job description signed and dated by the employee and the employer was on file in one of four personnel records of new hires.
The findings include:
The personnel records of four employees hired since the follow inspection conducted on November 22, 2011 were reviewed. A current job description was missing from one of the personnel records reviewed.
Personnel record # 1 was reviewed on 4/20/2012. There was no documentation of a job description in personnel record # 1.
The finding was discussed with the Clinical Supervisor and the Facility Director and was not disputed.
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Plan of Correction
1.MWFHE shall ensure that a current job description signed and dated by the employee and the employer is on file in the personnel records of new hires. The Office Manager shall conduct an audit of all personnel files to ensure that a job description is in each one. Additionally, the Office Manager shall ensure that job descriptions for new hires are signed and dated on the day of hire. The Office manager shall conduct weekly checks of newly hired personnel file to determine and ensure compliance with this standard. A job description has been signed, dated and placed in personnel record # 1. |
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 ensure that the client's medical history included the family medical history in three of seven client records.
The findings include:
Seven of the client records reviewed were due to include documentation of the clients' medical histories. The client's medical history in three of those client records did not include documentation of the clients' family medical history.
The findings were reviewed with the Clinical Supervisor and were not disputed.
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Plan of Correction
2.MWFHE shall ensure that a medical history for the client and the client's family is maintained in the client's record. All clinical staff shall review agency policy and State standards relating to this noted standard. The clinical supervisor shall conduct onsite refresher trainings relating to the documentation of completed client and family medical histories. Bi-weekly chart audits shall be conducted by the clinical supervisor to determine compliance with this standard. Any deficiencies found shall be addressed immediately by the primary clinician. The clinical supervisor shall recheck the record within 72 hours after alerting the primary therapist of the deficiency to ensure that the deficiency has been corrected. Finally, the clinical supervisor shall ensure that a family medical history, in all of the client records that were inspected, is completed and placed in the records. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to provide documentation of personal histories that included documentation of legal, military, recreational, educational and employment histories in five of six client records.
The findings include:
Components of the personal history were not documented in three of six client records reviewed.
Client record # 1 contained documentation of a personal history, but the personal history was missing the educational history.
Client record # 2 contained documentation of a personal history, but the personal history was missing the legal, employment, educational, recreational and sexual history components. The family history did not include documentation of family dynamics.
Client record # 4 contained documentation of a personal history, but the personal history was missing documentation of the employment history component.
Client record # 5 contained documentation of a personal history, but the personal history was missing documentation of the educational history component.
Client record # 6 contained documentation of a personal history, but the personal history was missing documentation of the legal and recreational components.
The findings were reviewed with the Clinical Supervisor and were not disputed.
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Plan of Correction
3. MWFHE shall ensure that documentation of clients personal histories include documentation of legal, military, recreational, educational and employment histories in all client records. The clinical supervisor shall provide additional training to all clinical staff relating to this standard. Clinical staff shall be informed that all components of the personal history require being addressed. Bi-weekly chart audits shall be conducted by the clinical supervisor to determine compliance with this standard. Any deficiencies found shall be addressed immediately by the primary clinician. The clinical supervisor shall recheck the record within 72 hours after alerting the primary therapist of the deficiency to ensure that the deficiency has been corrected. . Finally, the clinical supervisor shall ensure that a complete personal history is completed and placed in all of the client records that were inspected. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document psychosocial evaluations that addressed all required areas and were evaluative in those areas for two of five client records.
The findings include:
Psychosocial evaluations were due in five of the client records reviewed. The evaluations were missing composite pictures, client's problems/needs, coping mechanisms, the clients' attitudes toward treatment and the counselor's conclusions and impressions.
Client # 2 was admitted on 1/13/12. Documentation of the psychosocial evaluation in the client record did not include a composite picture of the client, the client's problems and needs, the client's coping mechanisms and attitude toward treatment and the counselor's conclusions and impressions.
Client # 5 was admitted on 1/31/12. Documentation of the psychosocial evaluation did not include the client's support systems and coping mechanisms.
This was reviewed with the Clinical Supervisor and was not disputed.
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Plan of Correction
4. MWFHE shall ensure that documentation of psychosocial evaluations address all required areas and are evaluative in those areas. The clinical supervisor shall provide additional training to all clinical staff relating to this standard. Clinical staff shall be informed that all areas of the psychosocial evaluation require being addressed. . Bi-weekly chart audits shall be conducted by the clinical supervisor to determine compliance with this standard. Any deficiencies found shall be addressed immediately by the primary clinician. The clinical supervisor shall recheck the record within 72 hours after alerting the primary therapist of the deficiency to ensure that the deficiency has been corrected. Finally, the clinical supervisor shall ensure that a complete psychosocial evaluation is completed and placed in all of the client records that were inspected. |
709.93(a)(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 include documentation of the dosage and frequency of use of client medications in one of two client records.
The findings include:
Nine client records were reviewed on 4/20/2012. Two client records listed medications that the client was currently using. There was no documentation of the dosage and frequency of use of the medication in one of two client records.
Client record #1 listed a medication the client was currently using. There was no documentation in the client record of the dosage or frequency of use of that medication.
This was reviewed with the Clinical Supervisor on 4/20/12 and she did not dispute the findings.
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Plan of Correction
5. MWFHE shall ensure that in client records that indicate the use of medication, included in the record is documentation of the dosage of the medication and the frequency for which it is prescribed. The clinical supervisor shall provide additional training to all clinical staff relating to this standard. Clinical staff shall be informed that when a client is prescribed medication such medication needs to be documented in the client's record along with the dosage of the medication and the frequency that it should be taken. Bi-weekly chart audits shall be conducted by the clinical supervisor to determine compliance with this standard. Any deficiencies found shall be addressed immediately by the primary clinician. The clinical supervisor shall recheck the record within 72 hours after alerting the primary therapist of the deficiency to ensure that the deficiency has been corrected. Finally, the clinical supervisor shall ensure that the dosage and frequency of prescribed medication is placed in all of the client records that were inspected. |
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 the facility's policy and procedure addressing follow up on clients who have left treatment, the facility failed to document attempts to follow up on clients in two of two client records.
The findings include:
The client records of two clients who had been discharged from the facility were reviewed on 4/20/2012. Facility policy and procedure requires that a follow up attempt be documented within 30 days of the discharge date. Documentation of attempts to follow up on the clients was missing from two of two client records.
Client # 8 was admitted into treatment on 11/30/2011 and was discharged on 2/22/2012. There was no documentation of an attempt to follow up on the client as of 4/20/2012.
Client # 9 was admitted into treatment on 10/26/2011 and was discharged on 1/9/2012. There was no documentation of an attempt to follow up on the client as of 4/20/2012.
The findings were discussed with the Clinical Supervisor and were not disputed.
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Plan of Correction
6. MWFHE shall ensure that agency policy and procedure that requires follow up attempts to be documented within 30 days of a client's discharge date is adhere to as stated. Documentation of attempts to follow up on the client after discharge shall be maintained in a file and managed by the office manager. The clinical supervisor shall provide additional training to all clinical staff and the office manager relating to this standard. Clinical staff and the office manager shall be informed that when a client is discharged, a follow-up must be completed within 30 days from date of discharge. Bi-weekly chart audits shall be conducted by the clinical supervisor to determine compliance with this standard. Any deficiencies found shall be addressed immediately by the office manager or designee. The clinical supervisor shall recheck the record/file within 72 hours after alerting the office manager of the deficiency to ensure that the deficiency has been corrected. Finally, the clinical supervisor shall ensure that follow-ups are completed and documented in all of the client records that were inspecte |