INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection conducted on February 9, 2024 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 and with input from both the employee and the supervisor, in five of six personnel records reviewed.
Employee #1 was hired as the project director on November 1, 2001. The individual training plan was last completed on November 21, 2022.
Employee # 2 was hired as the facility director on June 13, 2018. The individual training plan was last completed on December 20, 2022.
This is a repeat citation from the July 11, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Annual Training Plans are completed each year on all employees. MWFHE/DDAP does not have a specific timeframe policy to have training plans completed by the last shown date. The training plans are behind some within 1 month or 2 months. Presently those staff training that are not updated for are being completed no later than Friday, February 23, 2024.
Project Director - training Plan was completed and signed on 1/31/2023 his next training plan is not due until 1/31/2024.
Lead Counselor - training Plan was completed and signed on 1/12/2023 her next training plan is not due until 1/12/2024
Clinical Supervisor training Plan was conducted and signed on 1/31/2023 his next training plan is not due until 1/31/2024
Counselor - training Plan was completed and signed on 11/21/2023 his next training plan is not due until 11/21/2024 |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's October 2023 through January 2024 fire drill logs, the facility failed to ensure that unannounced fire drills were conducted at least once a month.
As of the date of the inspection, there were no fire drills logs, for the months of October 2023 through January 2024, submitted to the Licensing Representative.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
MWFHE mistakenly emailed the wrong copies of fire drills dates and can ensures unannounced fire drills were conducted at least once a month during the timeframe requested during the unannounced inspection by DDAP.
The MWFHE Director of Programs Operation email the corrected dated/copies of fire drills to the DDAP coordinator on 2/21/2024. |
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 eleven client records reviewed.
Client # 6 was admitted on July 22, 2022 and was still active at the time of the inspection. The release of information form to the funding source was completed on July 22, 2022 and expired on July 22, 2023. 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 22, 2023.
This is a repeat citation from the July 11, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The lead counselor will ensure all clients have updated consent to release information form and signed by the client no later than March 15, 2024.Presently the lead counselor is auditing all the charts that was reviewed during the inspection to ensure compliance.
The lead counselor and counselors will continue to audit all clients charts weekly and focus on areas including client consent forms to ensure all client consent form are updated. Updated consent form topic will also be added to the clinical weekly team meeting. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in one of eleven client records reviewed.
Client # 8 was admitted on February 6, 2024 and was still active at the time of the inspection. The consent to release information forms to a funding source and a laboratory were signed by the client on February 6, 2024, but both release forms did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The lead counselor/counselors will continue to audit clients' charts to ensure all information of the client is disclosed on the consent to release information forms when requested.
The counselor will audit the client #8 chart and complete the necessary changes needed to include the specific information to be disclosed to the funding source no later than March 8. 2024.
The Lead counselor will also add/review the topic of disclosing all client's information on the consent to release form in details during the Thursday weekly clinical team meeting. |
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 six applicable client records reviewed.
Client # 10 was admitted on December 15, 2023 and was still active at the time of the inspection. The client record did not document a medical history of the client at the time of the inspection.
Client # 11 was admitted on September 19, 2023 and was discharged on November 2, 2023. The client record did not document a medical history of the client at the time of the inspection.
This is a repeat citation from the July 11, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How: The drugs and alcohol counselor will complete all the missing information on the client intake, admission forms including the medical history no later than March 20, 2024. The Lead counselor then will review/audit client charts for this counselor no later than March 25, 2024, to ensure the client record meet compliance.
Monitor/Ways- The lead counselor will also provide training on various clinical topics including intake and admission documentation to ensure that the deficiency does not recur. training sign-in sheet will be available for review: |
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 five of five client records reviewed.
Client # 2 was admitted on December 21, 2023 and was still active at the time of the inspection. The client record did not document a drug and/or alcohol history of the client at the time of the inspection.
Client # 5 was admitted on September 12, 2023 and was still active at the time of the inspection. The client record did not document a drug and/or alcohol history of the client at the time of the inspection.
Client # 9 was admitted on December 15, 2023 and was still active at the time of the inspection. The client record did not document a drug and/or alcohol history of the client at the time of the inspection.
Client # 10 was admitted on December 15, 2023 and was still active at the time of the inspection. The client record did not document a drug and/or alcohol history of the client at the time of the inspection.
Client # 11 was admitted on September 19, 2023 and was discharged on November 2, 2023. The client record did not document a drug and/or alcohol history of the client at the time of the inspection.
This is a repeat citation from the July 11, 2023 annual licensing renewal 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 within 7 days. The Lead counselor then will review/audit client charts for this counselor on the 8th day of admission 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' during every Thursday clinical team meeting starting on March 7.2024. This will ensure that all comprehensive clinical documentation is completed within the clients' records.
The lead counselor will also provide training on various clinical topics including clinical documentation to ensure that the deficiency does not recur. training sign-in sheet will be available for review:
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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 five of five applicable client records reviewed.
Client # 2 was admitted on December 21, 2023 and was still active at the time of the inspection. The client record did not document a personal history of the client at the time of the inspection.
Client # 5 was admitted on September 12, 2023 and was still active at the time of the inspection. The client record did not document a personal history of the client at the time of the inspection.
Client # 9 was admitted on December 15, 2023 and was still active at the time of the inspection. The client record did not document a personal history of the client at the time of the inspection.
Client # 10 was admitted on December 15, 2023 and was still active at the time of the inspection. The client record did not document a personal history of the client at the time of the inspection.
Client # 11 was admitted on September 19, 2023 and was discharged on November 2, 2023. The client record did not document a personal history of the client at the time of the inspection.
This is a repeat citation from the July 11, 2023 annual licensing renewal 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 history part in the client record No later than March 28, 2024. The Lead counselor then will review/audit client charts for counselor no later than April 5, 2024, of documentation of complete history on the intake and admission forms to ensure the client record meet compliance.
Monitor/Ways-
The lead counselor will also provide training on various clinical topics including clinical documentation to ensure that the deficiency does not recur. training sign-in sheet will be available for review: |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan, which is to be developed with the client, in four of five applicable client records reviewed.
Client # 2 was admitted on December 21, 2023 and was still active at the time of the inspection. There was no individual treatment and rehabilitation documented in the client record at the time of the inspection.
Client # 5 was admitted on September 12, 2023 and was still active at the time of the inspection. There was no individual treatment and rehabilitation documented in the client record at the time of the inspection.
Client # 10 was admitted on December 15, 2023 and was still active at the time of the inspection. There was no individual treatment and rehabilitation documented in the client record at the time of the inspection.
Client # 11 was admitted on September 19, 2023 and was discharged on November 2, 2023. There was no individual treatment and rehabilitation documented in the client 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 drugs and alcohol counselors will ensure clients individual treatment and rehabilitation plan is put in the client chart at the time of inspection. Director of Program Operation will review charts from the inspection client list given by the inspector to ensure clients individual treatment and rehabilitation plan are in charts at the time of the inspection.
All missing individual treatment and rehabilitation plan missing at the time of the audit was put in the client's chart on February 12, 2024.
Monitor/Ways-
The Lead counselor will continue to audit charts to ensure client treatment and rehabilitation plan are in the client chart after completion to ensure the client record meet compliance.
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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 four of four applicable client records reviewed.
Client # 3 was admitted on May 3, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 1, 2023 and an update was due no later than August 1, 2023; however, the update was not completed at the time of the inspection.
Client # 4 was admitted on June 16, 2023 and was still active at the time of the inspection. A treatment plan update was completed on November 19, 2023 and another update was due no later than January 19, 2024; however, there was no update completed at the time of the inspection.
Client # 6 was admitted on July 22, 2022 and was still active at the time of the inspection. A treatment plan update was completed on June 17. 2023 and another update was due no later than August 17, 2023; however, there was no update completed at the time of the inspection.
Client # 7 was admitted on April 26, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 28, 2023 and an update was due no later than July 28, 2023; however, there was no update completed at the time of the inspection.
This is a repeat citation from the June 21, 2021, July 6, 2022, and July 11, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How: The drugs and alcohol counselors will ensure clients treatment and rehabilitation plans are reviewed and updated every thirty and sixty days.
Director of Program Operation will review charts from the inspection client list given by the inspector to ensure clients treatment and rehabilitation plans are updated and in client's charts at the time of the inspection.
All missing individual treatment and rehabilitation updated plan that was missing at the time of the audit was put in the client's chart on February 12, 2024.
Monitor/Ways-
The Lead counselor will continue to audit charts to ensure client treatment and rehabilitation plan are in the client chart after completion to ensure the client record meet compliance.
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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 assure that counseling services were being provided according to the individual treatment and rehabilitation plan in three of three applicable client records reviewed.
Client # 3 was admitted on May 3, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, dated June 1, 2023, indicated that the client was to receive weekly individual and weekly group counseling sessions. The only individual counseling sessions documented during the reviewed period of October 1, 2023 through the date of the inspection were on October 11, 2023, November 28, 2023, and January 12, 2023. The only group counseling sessions documented during the reviewed period of October 1, 2023 through the date of the inspection were on October 25, 2023, November 21, 2023, December 5, 2023, December 8, 2023, December 18, 2023, and November 12, 2024.
Client # 4 was admitted on June 16, 2023 and was still active at the time of the inspection. The treatment plan updates, dated September 11, 2023 and November 19, 2023, indicated that the client was to receive weekly individual and three group counseling sessions per week. The only individual counseling sessions documented during the reviewed period of October 1, 2023 through the date of the inspection were on October 11, 2023, October 31, 2023, November 9, 2023, December 14, 2023, and January 9, 2023. The only group counseling sessions documented during the reviewed period of October 1, 2023 through the date of the inspection were on November 8, 2023, November 13, 2023, December 4, 2023, December 6, 2023, January 3, 2023, and January 10, 2023.
Client # 6 was admitted on July 22, 2022 and was still active at the time of the inspection. The treatment plan update, dated June 17, 2023, indicated that the client was to receive weekly individual counseling sessions and three group counseling sessions per week. The only individual counseling sessions documented during the reviewed period of October 1, 2023 through the date of the inspection were on October 2, 2023, October 10, 2023, November 2, 2023, and January 9, 2024. The only group counseling sessions documented during the reviewed period of October 1, 2023 through the date of the inspection were on October 11, 2023, November 17, 2023, November 20, 2023, December 11, 2023, January 10, 2023, January 11, 2023, and January 12, 2023.
This is a repeat citation from the July 6, 2022 and July 11, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of September 2023, MWFHE only provides (3) three encounters per month of counseling services for Drugs and Alcohol Outpatient Clients: including 1 individuals session and 2 groups.
No later than March 15, 2024, MWFHE will modify all client's individual treatment and rehabilitation plans to show only (3) encounters of counseling services (1-indivudal session/2-groups) per month will be provided.
As of 2/29/2024 the Director and Lead Counselor has modified the individual treatment and rehabilitation plan to reflect the counseling services provided to D&A clients including 1-individual/ (2) group per month since October 2023.
The Director will also modify MWFHE program counseling services policy and procedures to reflect changes no later than 4/1/2024. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include a discharge summary, in one of one applicable client records reviewed.
Client # 11 was admitted on September 19, 2023 and was discharged on November 2, 2023. There was no discharge summary in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
How: The drugs and alcohol counselors will ensure clients discharge summary is put in the client chart at the time of inspection.
Director of Program Operation will review charts from the inspection client list first that is given by the inspector to ensure clients Discharge summary are in charts at the time of the inspection chart review.
The one (1) missing discharge summary missing at the time of the audit was put in the client's chart on February 15, 2024.
Monitor/Ways-
The Lead counselor will continue to audit charts to ensure discharge summary are in the client chart after completion by counselors to ensure the client record meet compliance.
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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, 2021, July 6, 2022, and July 11, 2023 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 February 9, 2024 licensing inspection.
A plan of correction for failing to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan was submitted and approved by the Department for the July 6, 2022, and July 11, 2023 annual licensing inspections. Failing to assure counseling services were being provided according to the individual treatment and rehabilitation plan was again found to be a deficiency in the February 9, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since the last June DDAP 2023 inspection MWFHE continue to work and train new staff on clinical procedure and documentation in order to improve on the DDAP plan of correction.
The unannounced DDAP inspection on Feb 9, 2024, showed some improvement. However, we recognize that there are still areas that need improvement. MWFHE will continue to work harder, and train new staff to improve their knowledge of clinical documentation mandates especially in the POC areas. Hopefully by the next DDAP inspection in July 2024 MWFHE will show better improvement to meet compliance in all areas on the POC.
The director and lead counselor will provide additional in-services training for all new/current clinician including topics of clinical documentation compliance, clinical documentation content, clinical documentation timeframe submission, and chart review/audit procedures (just to name a few), The in-service training will start on Mar 21, 2024, every Thursday during the clinical team meeting (verification of training will be provided)
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