INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.11(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 annual written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor in two of six personnel records reviewed.
Employee # 2 was hired as the facility director on June 13, 2018. The individual training plan was completed on December 20, 2022; however, there was no employee signature and there was no documentation that the plan was developed with input from the employee.
Employee # 3 was hired as a clinical supervisor on August 3, 2020. The individual training plan was completed on January 31, 2023; however, there was no employee signature and there was no documentation that the plan was developed with input from the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How:
the Director of Programs Operation currently (week of 8/7/2023) audit the 2 employee charts with missing signature on the training plan. Each employee signed the plan and self-reported (verified) that they had imput into the training plan
Montoring-the Director of Programs Operation will audit the employee charts after the Human Resource Cooridinator file documents this will ensure that all required signatures are on each training plan and other documents that require signatures. This method will ensure that the deficiency does not recur. |
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, the facility failed to provide CPR certification to a sufficient number of staff persons, so that at least one person trained in CPR is onsite during the project's hours of operations.
The facility provided copies of American Heart Association CPR certifications for several employees. Upon a review of the QR codes and eCard codes for each submitted employee's certification, it was found that the CPR certifications were not valid. The facility followed up with additional information, after the inspection, indicating that the CPR cards were not valid, and that the facility was not aware that the CPR cards were not valid. There was only one CPR card submitted, for a part-time employee, that was able to be verified as valid.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
How: To ensure facility provide an sufficient number of staff CPR certificate on site during hours of operations the HR Coordinator will start the process of scanning CPR QR. codes for all staff when submitted every two years for recertification to ensure each staff CPR certification is valid
Currently, the Lead counselor obtained her AED, Adult, Child, Infant CPR & AED Training (BLS) certification on 08/05/2023 : expire 08/05/2025
Director of Program Operation obtained her AED, Adult, Child, Infant CPR & AED Training (BLS) certification on 07/26/2023 : expired 07/26/2025
Monitor/Ways: All MWFHE staff will be responsible for renewing their own CPR certification. The HR Coordinator will create a table indicating within 60 days of what staff need to get CPR Recertification every two-years. The HR Coordinator will then notify staff as well as their supervisor by an email and/or phone call indicating the date when they need the updated CPR certification completed. If the HR Coordinator does not received an updated CPR certificate within 2-week of the 60-days then the staff will not be able to work until the CPR training is completed. Once completed each staff updated CPR certificate will will be review of the QR code by the HR Coordinator to ensure validity of the
CPR certification and to ensure that the deficiency does not recur.
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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that each clinical supervisor completed at least 12 clock hours of training annually during the facility's July 1, 2022 through June 30, 2023 training year in one of one applicable personnel record reviewed.
Employee # 3 was hired as a clinical supervisor on August 3, 2020. The personnel record documented 10 hours of training received during the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure 12 hours of training annually for clinical supervisor are completed
How: the Director of Program Operations/HR Cooridinator will review/auditing training certificate quarterly.
methods: the Director of Operations will provide other inservice training in order to increase annual training hours from 12 to 20 hrs to ensure the 12 hours are completed and that the deficiency does not recur.
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704.11(f)(1) LICENSURE Counselor's Trng Req
704.11. Staff development program.
(f) Training requirements for counselors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
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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 training annually during the July 1, 2022 through June 30, 2023 training year in one of two applicable personnel record reviewed.
Employee # 5 was hired as a counselor on July 30, 2018. The personnel record documented 23.25 hours of training received during the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure 25 hours of training annually for counselors are completed
How: the Director of Program Operations/HR Cooridinator will review/auditing training certificate quarterly.
methods: the Director of Operations will provide other inservice training in order to increase annual training hours from 25 to 30 hrs to ensure the 25 hours are completed and that the deficiency does not recur. |
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 a physical plant inspection, conducted on July 11, 2023 at approximately 2:30 PM, the facility failed to ensure that all exits from the nonresidential facility were unobstructed.
In the group room area, there was an exit from the facility leading to a back outside walkway that can only be unlocked and opened with a key. The key was not kept in the door, which causes the exit to be obstructed and unable to be opened by any individual during an emergency.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
how: The maintenance staff will replace the emergency exit door knob lock in the group room to a An interior thumb turn lock knob that can be opened and closed only from the inside of the group room by no later then September 15, 2023 to ensure the exit door is not obstructed and is able to be opened by any individual during an emergency.
methods/ways: the maintenance staff will continued monitoring the exit to ensure the door can be open by clients during and emergency and that the deficiency does not recur
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's July 2022 through May 2023 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
The facility's hours of operation were listed as Monday through Friday from 9:00AM to 5:00PM, and Saturday from 10:00AM to 2:00PM. All the fire drills conducted, during the reviewed period, were completed during the 12:00PM to 1:00PM hour. There were no fire drills conducted during the facility's morning or weekend hours of operation.
This is a repeat citation from the July 6, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How: the office managers will change the annual schedule for fire drills to different days of the week, and at different times of the day. This will begin starting on 9/1/2023.
Monitor/ways: The Director of Programs Operation will provide an inservices training on the DDAP regulations for Fire Drills and how fire Drills should be conducted. The Director will audit the fire drill binder weekly to ensure the fire drills are conducted on different days and have different times. This will ensire the deficiency does not recur. |
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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 4 was admitted on August 31, 2020 and was discharged on February 9, 2023. The release of information form to the funding source was completed on July 21, 2021 and the form expired on July 21, 2022. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after July 21, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
How: Lead counselor will provide inservices training for counselors on 9/14/2023 emphasizing the significance of counselors completing an informed and voluntary consent to release information form prior to the disclosure of information. As well as, discuss the significant of obtaining physical signatures during both telehealth and in-person services to clients.
Monitor/ways: The lead counselor will start conducting on 9/15/2023 chart audit/evaluation of the counselors progress during the weekly clinical team meeting to ensure this deficiency does not recur..
(training sign-in sheets will be available in training binder for review) |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in three of seven client records reviewed.
Client # 4 was admitted on August 31, 2020 and was discharged on February 9, 2023. The release of information form to the funding source was signed by the witness on July 21, 2021, but the form did not include the dated signature of the client.
Client # 6 was admitted on May 18, 2021 and was discharged on March 28, 2023. The release of information form to the funding source was signed by the witness on May 16, 2022, but the form did not include the dated signature of the client.
Client # 7 was admitted on January 21, 2021 and was discharged on April 8, 2023. The release of information form to the funding source was signed by the witness on January 21, 2022, but the form did not include the dated signature of the client.
This is a repeat citation from the June 21, 2012 and July 6, 2022 annual licensing inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
How: The Lead Counselor will provide on -going inservice training on clinical documentation including the significate of staff acquiring client signature and dates on all release of information forms on 9/28/2023.
Monitor/ways: Starting on 9/15/2023 the Clinical supervisor and couselors will review/audit client charts for signature and date on all release of information forms bi-weekly to ensure to this deficiency does not recur.
Client chart audit sheet will be avalable in audit binder for review of corrections made. |
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, as part of their intake and admission process, a medical history of the client in two of four applicable client records reviewed.
Client # 2 was admitted on March 24, 2023 and was active at the time of the inspection. There was no documentation of a medical history of the client in the record at the time of the inspection.
Client # 3 was admitted on April 5, 2023 and was active at the time of the inspection. There was no documentation of a medical history of the client in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How: The lead drug and alcohol counselor will ensure documentation correction are completed in client record no later then 9/15/2023 by the counselor. First the lead counselor and counselor will audit the client record and then complete an audit sheet to idenify the corrections thats need to be made. The counselor wil then make the necessary documentation correction to the client record no later then 8/24/2023. The counselor will then review he client record with the lead counselor to ensure correction was made acurrately to the documentation within the clients'records.
Monitor/Ways:
The Lead Counselor will conduct a
monthly client record review (audit) starting on 9/1/2023 the review will focus on ensuring all information is documented correctly including intake and admission forms, and the medical history part of the client record, This will ensure that the deficiency does not recur.
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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, as part of their intake and admission process, a drug and/or alcohol history of the client in two of four client records reviewed.
Client # 2 was admitted on March 24, 2023 and was active at the time of the inspection. There was no documentation of a drug and/or alcohol history of the client in the record at the time of the inspection.
Client # 3 was admitted on April 5, 2023 and was active at the time of the inspection. There was no documentation of a drug and/or alcohol history of the client in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How: The drug and alcohol counselor will complete all the missing information on the client intake, admission and drug and alcohol history part in the client record by 8/25/2023. The Lead counselor then will review/audit client charts for this counselor by 8/30/2023 to ensure the client record meet compliance.
Monitor/Ways- The Lead Counselor shall complete biweekly client charts audits along with reviewing the weekly audits sheet completed by this counselors' by 8/30/2023. This will ensure that all comprehensive clinical documentation is completed within the clients' records.
The lead counselor will also continue to facilitate weekly clinical team meeting every Thursday to review client charts, counselors' audits sheets and provide a training on various clinical topics including clinical documentation to ensure that the deficiency does not recur.
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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, as part of their intake and admission process, a personal history of the client in two of four client records reviewed.
Client # 2 was admitted on March 24, 2023 and was active at the time of the inspection. There was no documentation of a personal history of the client in the record at the time of the inspection.
Client # 3 was admitted on April 5, 2023 and was active at the time of the inspection. There was no documentation of a personal history of the client in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How: The drug and alcohol counselor will ensure documentation of the client personal history's information is documented on the intake and admission forms in the client record by 8/30/2023.
The drugs and alcohol counselor shall engage in weekly self-auditing under the supervision of the lead counselors to ensure documentation of the client personal history information are documented and, in the client, record. The lead counselor will audit the charts by 9/5/2023 to ensure the client personal history's information is documented in the client record as part of the intake and admission process.
Monitor/Ways- The Lead Counselor shall complete biweekly client charts audits beginning on 9/5/2023 along with reviewing the audits sheet conducted by the counselors. This will ensure the client's personal history information is documented and in the client record as part of the intake and admission process.
The lead counselor will continue facilitating weekly clinical team meetings on Thursdays for on-going discussion about chart compliance and including the client personal history information as part of the intake and admission process. The lead counselor will also continue monitoring to ensure the deficiency does not recur.
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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, as part of their intake and admission process, a psychosocial evaluation of the client in two of six client records reviewed.
Client # 2 was admitted on March 24, 2023 and was active at the time of the inspection. There was no documentation of a psychosocial evaluation of the client in the record at the time of the inspection.
Client # 3 was admitted on April 5, 2023 and was active at the time of the inspection. There was no documentation of a psychosocial evaluation of the client in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How: The drug and alcohol counselor will ensure the psychosocial evaluation is in the client record by 8/30/2023. The drugs and alcohol counselor shall engage in weekly self-auditing under the supervision of the lead counselors to ensure all clinical documents are completed and, in the client, record including the psychosocial evaluation. The lead counselor will start auditing and review the chart on 9/5/2023 to ensure the psychosocial evaluation is in the client record.
Monitor/Ways- The Lead Counselor shall complete biweekly client charts audits beginning on 9/5/2023 along with reviewing the audits sheet conducted by the counselors. This will ensure that all clients' documents are in the client record included, the psychosocial evaluation.
The lead counselor will continue facilitating weekly clinical team meetings on Thursdays for on-going discussion to ensure client chart compliance and ensuring that all clinical documentation are completed by counselors and in the client chart. The lead counselor will also continue monitoring to ensure the deficiency does not recur.
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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 review and update treatment and rehabilitation plans at least every sixty days in five of seven applicable client records reviewed.
Client # 1 was admitted on March 23, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 11, 2023 and the first update was due no later than June 11, 2023; however, the update was not completed at the time of the inspection.
Client # 2 was admitted on March 24, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 11, 2023 and the first update was due no later than June 11, 2023; however, the update was not completed at the time of the inspection.
Client # 4 was admitted on August 31, 2020 and was discharged on February 9, 2023. A treatment plan update was completed on June 17, 2022 and the next update was due no later than August 17, 2022; however, there was no update completed prior to discharge.
Client # 5 was admitted on September 28, 2022 and was discharged on March 30, 2023. A treatment plan update was completed on December 22, 2022 and the next update was due no later than February 22, 2022; however, there was no update completed prior to discharge.
Client # 7 was admitted on January 21, 2021 and was discharged on April 8, 2023. A treatment plan update was completed on April 21, 2022 and the next update was due no later than June 21, 2022; however, there was no update completed prior to discharge.
This is a repeat citation from the June 21, 2012 and July 6, 2022 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How: The drug and alcohol counselor will complete the updated treatment and rehabilitation plans missing in the client record by 8/25/2023. The Lead counselor then will review/audit client charts by 8/30/2023 to ensure the treatment and rehabilitation plans have been updated.
Monitoring/Ways
The counselor will monitor and audits client charts weekly beginning on 8/25/2023 and note on the audit sheet when the next updated treatment plan is due. During the weekly team meeting on Thursday 1X month the lead counselor will then review the audit sheets from the counselor with the names of the client who need an updated treatment plan and instruct the counselors to complete the update treatment and rehabilitation plans within the timeframe she gives them. After counselor completes the updated treatment and rehabilitation plan, she then will approve them to submit an invoice for payroll payment. The counselor will continue monitoring to ensure the deficiency does not recur.
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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 facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in two of four applicable client records reviewed.
Client # 2 was admitted on March 24, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, dated April 11, 2023, indicated that the client was to receive weekly individual counseling sessions. There was no documentation, in the record, of weekly individual counseling session occurring during the weeks of May 7, 2023 - May 13, 2023; May 14, 2023 - May 20, 2023; June 4, 2023 - June 10, 2023; June 18, 2023 - June 24, 2023 and June 25, 2023 through July 1, 2023.
Client # 3 was admitted on April 5, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, dated May 4, 2023, indicated that the client was to receive weekly individual counseling sessions. There was no documentation, in the record, of weekly individual counseling session occurring during the weeks of May 7, 2023 - May 13, 2023; May 14, 2023 - May 20, 2023; May 21, 2023 - May 27, 2023; and May 28, 2023 - June 3, 2023.
This is a repeat citation from the July 6, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How: Beginning on 8/30/2023 the Drug and Alcohol Counselors will complete the necessary comprehensive case management notes or appropriately labeled as a "No-Show" entry in the client's chart to show no treatment services was provided although, the client is still active.
Monitor/Ways
The Lead counselor will begin on 9/1/2023 reviewing the counselors' audits sheets/auditing clients charts to ensure they completed the no-show notes for clients record who miss their treatment appointment. The lead counselor will ensure comprehensive case management note or appropriately labeled as a "No-Show" entry are in the client's chart to show no treatment services was provided although, the client is still active and also to ensure this deficiency does not recur.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to review and update treatment and rehabilitation plans at least every sixty days was submitted and approved by the Department for the June 21, 2012 and July 6, 2022 annual licensing inspections. Failing to review and update treatment and rehabilitation plans at least every sixty days was again found to be a deficiency in the July 11, 2023 licensing inspection.
A plan of correction for failing to document the dated signature of the client on release of information forms was submitted and approved by the Department for the June 21, 2012 and July 6, 2022 annual licensing inspections. Failing to document the dated signature of the client on release of information forms was again found to be a deficiency in the July 11, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How: Beginning on 9/1/2023 The Director of Programs Operations and the Lead Counselor will work diligently to comply with the plans of correction that were approved by the Department. The Director of Programs Operations and the Lead Counselor will meet monthly to review DDAP approved plan of corrections and to ensure the agency is progressing and complying with DDAP approve plan.
Beginning on 9/1/2023 The Director of Programs Operations and the Lead Counselor will start reviewing all counselors' work invoices for treatment services provided as well as the completed clinical documentation of the treatment services he/she is submitting on the invoices to receive payment. This will ensure that counselors have completed the clinical documentation work for treatment services they provided to the clients.
The Lead Counselor will also provide a monthly status report on 9/1/2023 including improvement of the counselors' work performance in the areas of chart audits, all client's information documented on the intake/admission forms, and the client history, no show notes for clients who miss treatment appointments, and updates on counselors completing clients updated treatment and rehabilitation plans in the timeframe. The status report will also provide information on counselors struggling to meet the clinical documentation compliance.
The Director of Programs Operation will work with the counselors who are struggling with maintaining clinical documentation compliance and develop a 30-day plan of correction to improve his/her work performance. If counselors do not improve further disciplinary action will be taken.
Monitoring/Ways: Beginning 9/12023 the lead counselor will continue to monitor and audits client charts bi-weekly and note on the audit sheets from the counselors what is due and what clinical documentation needs to be corrected and/or completed. The lead counselor during the weekly team meeting on Thursday will review with counselors the clients who need updated treatment plan and discuss clients' records who have missing clinical documentation noted from the counselor's audit sheets. The lead counselors will then give counselors a timeframe to complete the work. Once all documentation is completed the lead counselor will then approve them to submit an invoice for payroll payment. The Director of Program Operation and the Lead counselor will continue monitoring to ensure the agency is progressing and complying with DDAP approve plan.
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