INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26, 2007 through June 27, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 19, 2007.
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Plan of Correction
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
The counselor assistant, employee #3, was not supervised by a full-time counselor or clinical supervisor.
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Plan of Correction
Men & Women For Human Excellence, Inc. Drug and Alcohol outpatient treatment program has hired a Full time Clinical Supervisor who will began employment on July 23, 2007. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
The project failed to document an overall training plan for the 2007 training year.
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Plan of Correction
The Executive Director will be responsible for the completion of Men & Women For Human Excellence, Inc Drug and Alcohol outpatient program overall training plan for each upcoming year. The overall training plan will be completed in January of each year. |
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
Documentation of HIV/AIDS and TB/STD training was not provided for employee #1. Documentation of HIV/AIDS training was not provided for employee #3.
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Plan of Correction
All employees of Men & Women For Human Excellence, Inc. Drug and Alcohol outpatient program have been scheduled for HIV/AIDS as well as TB/STD tainings for September 17, 2007. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
The facility failed to provide training hours for employee #1.
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Plan of Correction
Men & Women For Human Excellence, Inc. Executive Director will ensure that all management staff have completed their scheduled training 12 hours for the upcoming year. The Executive Director will meet with each management staff (Facilty/Program Director/Clinical Supervisor) to ensure that training hours are completed. |
709.22(e)(1) 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:
(1) Activities and accomplishments of the preceding year.
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Observations
The annual report did not include the activities and accomplishments of the preceding year.
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Plan of Correction
The President shall provide a yearly report that will enclude Men & Women for Human Excellence, Inc. activities, accomplishments and fiscal information from the pervious year. This report will be available by June of each year. |
709.22(e)(3) 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:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
The annual report did not include a statement disclosing the names of officers, directors, and principal shareholders.
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Plan of Correction
The President of Men & Women For Human Excellence, Inc will ensure that the agency's discloses the names of the officers and directors of the agency in the annual report, which will be available in June of each year. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The project's timeframe for the completion of the medical history, drug and/or alcohol history, personal history, and the psychosocial evaluation within 15 days from the client's date of admission was not congruent with the practice of completing these clinical record items within 30 days of the client's admission date.
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Plan of Correction
Men & Women For Human Excellence, Inc. has revised its current timeframe within its policy to show that there will be a 30 day period to have medical history, drug and/or alcohol history, personal hostory and psychosocial evaluation completed from the admission of a client. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
The form entitled "Information Privacy Notice" did not address the release of information without client consent in cases of suspected child abuse.
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Plan of Correction
The Executive Director will revise the "Information Privacy Notice" form to address child abuse issues. |
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
The proposed type of support service was not documented on the individual treatment and rehabilitation plan in one of two client records reviewed, # 2.
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Plan of Correction
The clinical Supervisor will ensure that all clinical staff document support services on client's individual treatment plans. The Clinical Supervisor will review all staff documentation on a monthly basic. Also, MWFHE, Inc. will conduct in-house trainings in August 2007 on treatment planning. |
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
The treatment plan update was completed one month late and failed provide an assessment of progress on previously stated goals in one of one client records reviewed, #6.
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Plan of Correction
The Clinical Supervisor will ensure that clinical staff complete updated treatment plans on time, sixty days after client's comprehensive treatment plans are completed. Clinical Supervisor will conduct trainnings on treatment plan updates during the month of August 2007, also the clincial supervisor will review client's records on a monthly basic to ensure continued compliance. |