INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 17, 2014 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) form, the facility failed to document a complete SRFSR form on time at the time of the facility's site visit.
The findings include:
On May 6, 2014, the Licensing Specialist requested the facility to submit the SRFSR form by May 27, 2014. The Licensing Specialist also reminded the facility on May 21, 2014 to submit the SRFSR form by May 27, 2014. However, the SRFSR form was not presented for review until May 28, 2014 and the form was not legible. On June 12, 2014, the Licensing Specialist requested the facility again to submit the SRFSR by June 13, 2014. However, several areas on the form were incomplete and not accurate. On June 16, 2014, the Licensing Specialist reviewed the SRFSR form with the facility, informed the facility what corrections need to be made on the form, and requested the facility to re-submit the form upon the Licensing Specialist's arrival for the inspection. The facility submitted the form upon the Licensing Specialist's arrival for inspection but there were still areas on the form incomplete and not accurate. The Licensing Specialist reviewed the SRFSR form with the facility again, informed the facility what corrections need to be made on the form, and requested the facility to re-submit the form within an hour. However, the facility did not submit the SRFSR form until the end of the inspection and there were areas again on the form that were incomplete and not accurate.
The findings were confirmed during an interview with the project director on June 17, 2014 at approximately 3:40 P.M.
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Plan of Correction
MWFHE shall document a complete SRFSR form during the pre-submission period and if needed at the time of the project's site visit The clinical director/supervisor shall be responsible for completing the form at least two weeks prior to the site visit and present it to the Executive Director for final review and approval. MWFHE will immediately be in full compliance with this standard. |
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 in one of three personnel records reviewed.
The findings include:
Three personnel records were reviewed for documentation of the qualifications for the position of counselor. The facility failed to ensure that employees # 5 met the qualifications for the position of counselor.
Employee # 5 was hired as a counselor on January 21, 2014. The facility failed to verify that employee # 5 met the educational qualifications for the position of counselor. Employee # 5's personnel record did not include documentation of an application, resume, and any other documentation of work experience. Also, employee # 5's personnel record did not include documentation of a degree, transcript, a professional license, or any other documentation of education.
The findings were confirmed during an interview with the project director on June 17, 2014 at approximately 3:40 P.M.
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Plan of Correction
MWFHE shall ensure that counselors meet at least one of the following groups of qualifications: (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.
With respect to this deficiency, the clinical director/supervisor/office manager shall review all personnel files to ensure compliance with this standard. The office manager/clinical supervisor shall within 72 hours of the hiring of a new employee, review that employee's file to determine and ensure that all required documents are present in the file. Such review shall be documented for ongoing review. Also, with respect to employee # 5, the clinical supervisor has verified that employee # 5 meets the educational qualifications for the position of counselor. An application and resume has been placed in employee # 5 personnel file. Also, employee # 5's personnel record now includes documentation of a degree and an official transcript.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training in one of two personnel records reviewed.
The findings include:
Two personnel records requiring documentation of 25 clock hours of annual training were reviewed on June 17, 2014. The facility failed to provide documentation of 25 clock hours of annual training in the personnel record of employee # 7.
Employee # 7 was hired as a counselor on August 13, 2012. Personnel record # 7 only contained documentation of 12 clock hours of training for the 2013 training year.
The findings were confirmed during an interview with the project director on June 17, 2014 at approximately 3:40 P.M.
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Plan of Correction
MWFHE shall ensure that each counselor complete at least 25 clock hours of training annually in areas such as: "(i) Client recordkeeping. (ii) Confidentiality. (iii) Pharmacology. (iv) Treatment planning. (v) Counseling techniques. (vi) Drug and alcohol assessment. (vii) Codependency. (viii) Adult Children of Alcoholics (ACOA) issues. (ix) Disease of addiction. (x) Aftercare planning. (xi) Principles of Alcoholics Anonymous and Narcotics Anonymous. (xii) Ethics. (xiii) Substance abuse trends. (xiv) Interaction of addiction and mental illness. (xv) Cultural awareness. (xvi) Sexual harassment. (xvii) Developmental psychology. (xviii) Relapse prevention. If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision." With respect to this standard, the clinical director/supervisor shall ensure that each counselor completes at least 25 clock hours of annual training. The clinical supervisor shall collaborate with counselors to identify acceptable trainings, dates/times when trainings are offered, and location of training. Completion of trainings shall be maintained in the employee's file for quarterly review by the clinical director/supervisor. The clinical supervisor has met with Employee # 7 to discuss compliance with this standard. Additionally, the clinical supervisor will make sure employee # 7 and all other required employees that are counselors complete 25 clock hours of annual training for the 2014 training year and upcoming training years. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on an interview with the project director, the facility failed to provide an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility's 2012 to 2013 fiscal year ended on June 30, 2013.
The Licensing Specialist made several requests between 5/6/2014 and 6/17/2014 to see a copy of the facility's annual audit of financial activities associated with the project's drug/alcohol abuse services for the facility's 2012 - 2013 fiscal year. The facility failed to present an annual audit of financial activities associated with the project's drug/alcohol abuse services for the facility's 2012 - 2013 fiscal year.
The findings were confirmed during an interview with the project director on June 17, 2014 at approximately at approximately 12:30 P.M.
This is a repeat citation. The facility was cited on June 5, 2013; June 28, 2012; April 20, 2012; and December 14, 2011 for noncompliance with this standard.
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Plan of Correction
MWFHE shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services to ensure compliance with this standard. The Executive Director shall ensure that the facility provide an annual audit of financial activities associated with the project's drug/alcohol abuse services for the facility's 2012 - 2013 fiscal year. The Executive shall meet with the accountant on a quarterly basis to determine the progress with completing the audit in timely manner and presented as the standard requires. With respect to this deficiency, the CEO has retained the services of an independent public accountant to complete the audit for the 2012 ? 2013 fiscal year.
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709.26(d)(1) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(1) The application for employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel records includes the application for employment and verification of training experience and professional licensure or registration in one of four personnel records reviewed.
The findings include:
Four personnel records were reviewed for documentation of application for employment and verification of training experience and professional licensure or registration. The facility failed to ensure that personnel record # 5 included documentation of an application for employment and verification of training experience and professional licensure or registration.
Employee # 5 was hired as a counselor on January 21, 2014. However, personnel record # 5 did not include documentation of an application for employment and verification of training experience and professional licensure or registration.
The findings were confirmed during an interview with the project director on June 17, 2014 at approximately 3:40 P.M.
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Plan of Correction
MWFHE shall ensure that personnel records include the application for employment. The Clinical Director/supervisor/office manager shall within 72 hours review all newly hire employee's personnel files to determine compliance with this standard. Where non compliance is indicated the employee in question shall immediately complete the required document(s). With respect to this deficiency, documentation of verification of training experience and professional licensure or registration has been placed in employee # 5's personnel record. The clinical supervisor/office manager will audit the personnel records on a monthly to quarterly basis to ensure that an application for employment and documentation of verification of training experience and professional licensure or registration is in placed in each employee's personnel record. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to provide a written procedure that complied with 4 Pa. Code 255.5 (relating to project and coordinating bodies: disclosure of client-oriented information) regarding the maintenance and security of the records and staff access to client records.
The findings include:
On June 17, 2014, the facility's policies and procedures on confidentiality were reviewed. The facility's policies and procedures on confidentiality did not include documentation of the person responsible for the maintenance and security of the client records. The facility's updated policies and procedures on confidentiality regarding staff access to client records did include documentation of the project staff that had access to the client records. However, the policies and procedures regarding staff access to client records were not approved by the governing body.
The findings were confirmed during an interview with the project director on June 17, 2014 at approximately 3:40 P.M.
This is a repeat citation. The facility was cited on June 5, 2013; June 28, 2012; and April 20, 2012 for noncompliance with this standard.
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Plan of Correction
MWFHE shall provide a written procedure that complies with 4 Pa. Code 255.5 (relating to project and coordinating bodies: disclosure of client-oriented information) regarding the maintenance and security of the records and staff access to client records. The executive director shall ensure compliance with this standard. The executive director shall on a quarterly basis review the policy and procedure manual to determine compliance with this standard and if noncompliance (policy that has not been presented to the board for review and adoption) is indicated, the executive director is to present the issue to governing body at the next scheduled board meeting with the outcome documented for future review. With respect to this deficiency, the facility's updated policies and procedures on confidentiality regarding staff access to client records shall be presented to the governing body at its next scheduled meeting for approval. The Executive Director will make sure that the updated policies and procedures on confidentiality regarding staff access to client records once it is approved by the board will remain in place at the facility. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to ensure that counseling was provided on a regular and scheduled basis in five of fifteen client records reviewed.
The findings include:
Fifteen client records were reviewed from June 17, 2014 to ensure that counseling was provided on a regular and scheduled basis. The facility failed to ensure that counseling was provided on a regular and scheduled basis in client records # 11, 12, 13, 14 and 15.
Client # 11 was admitted on 8/15/13 and discharged on 11/12/13. However, client # 11's last counseling session was 9/25/13.
Client # 12 was admitted on 9/16/13 and discharged on 11/18/13. However, client # 12's last counseling session was 10/23/13.
Client # 13 was admitted on 9/19/13 and discharged on 12/2/13. However, client # 13's last counseling session was 10/15/13.
Client # 14 was admitted on 9/5/13 and discharged on 12/23/13. However, client # 14's last counseling session was 10/8/13.
Client # 15 was admitted on 9/24/13 and discharged on 11/22/13. However, client # 15's last counseling session was 10/30/13.
The findings were confirmed during an interview with the project director on June 17, 2014 at approximately 3:40 P.M.
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Plan of Correction
MWFHE/Program Director/Clinical Supervisor shall ensure that counseling is provided on a regular and scheduled basis and is documented. With respect to this deficiently, the Clinical Supervisor shall monitor no shows on a weekly basis. Also, clinicians shall turn in daily sign-in sheets along with case management notes indicating no shows; and the Clinical Supervisor shall maintain an active list of all PIRs who are within a week of their 30 day discharge date and initiate appropriate action. The Clinical Supervisor will review documents as followed: Week one of client no show will require counselor to document with a case management note with no show date, counselor clinical intervention for attempting re-engaging of client and counselors plan; week two with no show of client, counselor will repeat completing of a case management note to include other supports, contacts and resources with appropriate releases of consent to attempt to locate and re-engage client; week three, counselor will complete a seven day letter to be mailed describing the date of last visit and potential discharge date should client not respond within specified time; and week four, counselor will discharge client and attach client's ongoing after care plan. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual that included a comprehensive treatment and rehabilitation plan in two of fifteen client records reviewed and follow-up information in seven of fifteen client records reviewed.
The findings include:
One June 17, 2014, fifteen client records requiring documentation of a complete client record were reviewed. The facility failed to document the comprehensive treatment and rehabilitation plan in client records # 8 and 14 and follow-up information in client records # 7, 8, 9, 10, 11, 12 and 13.
Client # 7 was admitted July 30, 2013 and discharged October 4, 2013. The follow-up information was due April 4, 2014. However, client record # 7 did not include documentation of follow-up information as of June 17, 2014.
Client # 8 was admitted August 26, 2013 and discharged November 11, 2013. The comprehensive treatment and rehabilitation plan was due September 26, 2013 and the follow-up information was due May 11, 2014. However, client record # 8 did not include documentation of a comprehensive treatment and rehabilitation plan or follow-up information as of June 17, 2014.
Client # 9 was admitted July 9, 2013 and discharged October 17, 2013. The follow-up information was due April 17, 2014. However, client record # 9 did not include documentation of follow-up information as of June 17, 2014.
Client # 10 was admitted August 27, 2013 and discharged November 14, 2013. The follow-up information was due May 14, 2014. However, client record # 10 did not include documentation of follow-up information as of June 17, 2014.
Client # 11 was admitted August 15, 2013 and discharged November 12, 2013. The follow-up information was due May 12, 2014. However, client record # 11 did not include documentation of follow-up information as of June 17, 2014.
Client # 12 was admitted September 16, 2013 and discharged November 18, 2013. The follow-up information was due May 18, 2014. However, client record # 12 did not include documentation of follow-up information as of June 17, 2014.
Client # 13 was admitted September 19, 2013 and discharged December 2, 2013. The follow-up information was due June 2, 2014. However, client record # 13 did not include documentation of follow-up information as of June 17, 2014.
Client # 14 was admitted September 5, 2013 and discharged December 23, 2013. The comprehensive treatment and rehabilitation plan was due October 5, 2013. However, client record # 14 did not include documentation of a comprehensive treatment and rehabilitation plan as of June 17, 2014.
The findings were confirmed during an interview with the project director on June 17, 2014 at approximately 3:40 P.M.
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Plan of Correction
Office manager will be responsible for collecting and filing of follow-up information. Clinical Supervisor will create a spread sheet to be updated per receipt of each discharge by clinicians. The Office manager will update spread sheet indicating the follow up date and also the comment section has been completed. Office Manager shall email to Clinical Supervisor the updated spread sheet on a weekly basis for review. The clinical supervisor will document follow-up information for clients # 7, 8, 9, 10, 11, 12, 13, and 14. Moving forward, the clinical supervisor will make sure that follow-up information is completed on time for all discharged clients and that comprehensive treatment plan is completed on time for all clients. |