INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 2021 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 five of seven personnel record reviewed.
Employee # 1 was hired as the project director on November 1, 2021. The individual training plan was signed by the employee on January 21, 2021; however, there was no indication that it was developed with input from the supervisor.
Employee # 3 was hired as a clinical supervisor on January 29, 2018. The individual training plan was signed by the employee on February 3, 2021; however, there was no indication that it was developed with input from the supervisor.
Employee # 4 was hired as a counselor on August 3, 2020. There was no individual training plan documented, for the current training year, in the personnel record at the time of the inspection.
Employee # 6 was hired as a counselor on June 11, 2019. There was no individual training plan documented, for the current training year, in the personnel record at the time of the inspection.
Employee # 7 was hired as a counselor on January 18, 2018. There was no individual training plan documented, for the current training year, in the personnel 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
In order to ensure that all required staff /supervisor input and signatures are completed on the training development plan the supervisor will start reviewing the training development plan with staff during the 1st supervision session, and during staff annual performance review. This will ensure that both signature (staff/supervisor) are completed and the staff have input on his/her training plan. The HR manager will also audit employees charts monthly to ensure all documents have the required signature and staff input as required. The individual training plan will be completed with input from both the supervisor and employee listed no later then 9/30/2021. 12/30/20 |
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
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in two of four applicable personnel records reviewed.
Employee # 3 was hired as a clinical supervisor on January 29, 2018 and was due to have HIV/AIDS training no later than January 29, 2020. There was no documentation of the completed HIV/AIDS training in the personnel record at the time of the inspection.
Employee # 6 was hired as a counselor on June 11, 2019 and was due to have HIV/AIDS training and TB/STD training no later than June 11, 2020. There was no documentation of the completed HIV/AIDS training and TB/STD and other health related topics training in the personnel 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
All supervisors are required to ensure that staff under there department will receive 6 hours of HIV/AIDS training and at least 4 hours of TB/STD within a year of hire. If the employee have not taken the training upon hire the supervisor will then schedule the HIV/AIDS and TB/STD training. The supervisors will also ensure that support/clinical staff bring copies of the training upon hire if they have taken them already. The project director will also add staff training topic to the administrative weekly meeting agenda and discuss. This will ensure all mandated training is completed within the required timeframe. The HIV/AIDS and/or TB/STD training will be scheduled and completed for the employees listed no later then 12/30/2021 |
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
Based on a review of personnel records, the facility failed to ensure that the project director and facility director completed at least 12 clock hours of training annually during the facility's June 1, 2020 through May 31, 2021 training year in two of two applicable personnel records reviewed.
Employee # 1 was hired as the project director on November 1, 2021. The personnel record documented 4 hours of training received during the training year reviewed.
Employee # 2 was hired as the facility director on June 13, 2018. The personnel record documented 4 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
The director will ensure that the required 12 hours of training annually for the project & facility director are completed annually as required. The HR manager will audit the training records monthly and review the training completed to ensure that annual training (12 hours ) are completed by the the project & facility director.
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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 training annually during the facility's June 1, 2020 through May 31, 2021 training year in one of two applicable personnel record reviewed.
Employee # 6 was hired as a counselor on June 11, 2019. The personnel record documented 12 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
The director will ensure each counselor complete 25 clock hours of training annually by reviewing each counselor (counselors' chart) training record monthly. The HR manager will also audit the training records monthly and review the training completed to ensure that annual training (25 hours ) f are completed annually. |
709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
Based on a review of personnel records, the facility failed to document the written verification of qualifying professional credentials in one of three applicable personnel records reviewed.
Employee # 4 was hired as a counselor on August 3, 2020. There was documentation in the personnel record that the employee obtained a bachelor's degree; however, there was no documentation of the major to verify that the degree is a counselor-qualifying degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon new counselor hiring the Project Director will ensure the HR manager obtain clear, legible, diplomas, degree documents to review and verify before hire -as well as completing the written verification of qualifying professional credential form. This will ensure the counselor educational major is verify and his/her degree qualify for the position. The project director will also review new hire (counselor) packets before hiring to ensure the counselor degree qualify and the written verification of qualifying professional credential is documented (completed) and in his/her personnel records.
(The employee who Bachelor 's degree major was not verify although we did have the degree , but not the major clarity). This employee no longer works for MWFHE and we was unable to get verification of her degree to check if it qualify for a counselor.
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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 seven of seven applicable client records reviewed. In every client record reviewed, there was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The lead counselor will ensure the consent to release information form is signed by all client and documented in the record during the time of intake.
The lead counselor will review all new intake packets to ensure that the intake coordinator has completed the forms at the time of the assessment.
The lead counselor will also have 1x month supervision with the Intake coordinator to review clients' charts to ensure the consent to release information form has been completed in its entirely. The new ROIs with clients signatures will be signed immediately (or no later than (8/1/2021) for all active clients as well as for new admits during their first session. |
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 five of seven client records reviewed.
Client # 1 was admitted on January 21, 2021 and was still active at the time of the inspection. The release of information forms to an emergency contact, a laboratory, a funding source and a parole officer were signed and dated by the witness on January 21, 2021, but all of the release forms failed to document the specific information to be disclosed.
Client # 2 was admitted on January 6, 2021 and was still active at the time of the inspection. The release of information forms to an emergency contact, a laboratory and a funding source were signed and dated by the witness on January 6, 2021, but all of the release forms failed to document the specific information to be disclosed.
Client # 4 was admitted on January 22, 2021 and was discharged on April 9, 2021. The release of information forms to a laboratory and a funding source were signed and dated by the witness on January 22, 2021, but both of the release forms failed to document the specific information to be disclosed.
Client # 5 was admitted on February 19, 2021 and was discharged on June 15, 2021. The release of information forms to a laboratory, a funding source and a social worker were signed and dated by the witness on February 19, 2021, but all of the release forms failed to document the specific information to be disclosed.
Client # 6 was admitted on December 2, 2020 and was discharged on June 7, 2021. The release of information forms to a laboratory and a funding source were signed and dated by the witness on December 2, 2020, but both of the release forms failed to document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor /lead counselor will audit clients charts weekly reviewing all forms in client chart to ensure counselors' are documenting the specific information to be disclosed for compliance including the release of information form, and laboratory, funding sources, and parole officers information. The clinical supervisor /lead counselor will document all incomplete and missing information on the audit form and instruct the counselor to make the correction.
The new ROIs with the specific information to be disclosed will be signed for any active clients listed no later then 8/30/2021 or sooner. |
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 seven of seven applicable client records reviewed. Every release of information form in every client record reviewed failed to document the dated signature of the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor/lead counselor will audit client charts weekly to ensure the counselor have obtain/documented the dated signature of the client on release of information forms. The clinical supervisor/lead counselor will utilize the audit sheet to identify what information is missing on the on release of information forms as well as other document and return to counselor to make corrections if needed. Once the chart audit is completed the audit forms will be place in the weekly audit binder.
The new ROIs will be signed for any active clients on the list no later then 8/30/2021 or sooner.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in every release of information form in five of seven client records reviewed.
Client # 1 was admitted on January 21, 2021 and was still active at the time of the inspection. The release of information forms were signed by the witness on January 21, 2021, but there was no documentation that a copy of any of the forms were offered to the client.
Client # 2 was admitted on January 6, 2021 and was still active at the time of the inspection. The release of information forms were signed by the witness on January 6, 2021, but there was no documentation that a copy of any of the forms were offered to the client.
Client # 4 was admitted on January 22, 2021 and was discharged on April 9, 2021. The release of information forms were signed by the witness on January 22, 2021, but there was no documentation that a copy of any of the forms were offered to the client.
Client # 5 was admitted on February 19, 2021 and was discharged on June 15, 2021. The release of information forms were signed by the witness on February 19, 2021, but there was no documentation that a copy of any of the forms were offered to the client.
Client # 6 was admitted on December 2, 2020 and was discharged on June 7, 2021. The release of information forms were signed by the witness on December 2, 2021, but there was no documentation that a copy of any of the forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor/lead counselor will audit client charts weekly to ensure the counselor document (check off) on the release of information form that a copy of a client consent was offered. The clinical supervisor/lead counselor will utilize the audit sheet to identify what information is missing on the on release of information forms as well as other document and return to counselor to make corrections if needed. Once the chart audit is completed the audit forms will be place in the weekly audit binder .
As July 1, 2021 the new ROIs that indicate if a copy was offered to the client is being signed for any active clients.
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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, developed with the client, in four of seven client records reviewed.
Client # 1 was admitted on January 21, 2021 and was still active at the time of the inspection. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client # 2 was admitted on January 6, 2021 and was still active at the time of the inspection. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client # 4 was admitted on January 22, 2021 and was discharged on April 9, 2021. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client # 7 was admitted on November 24, 2020 and was discharged on January 11, 2021. There was no individual treatment and rehabilitation plan 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
The clinical supervisor will discuss with counselors every Friday during the clinical team meeting the significant of developing an individual treatment and rehabilitation plan with their clients and completing them within the required timeframe. The clinical supervisor will also conduct weekly chart audit before the team meeting identifying counselors who did not complete and/or develop an individual treatment and rehabilitation plan with their client. The clinical supervisor will then meet separately with each counselor after the meeting who have not develop an individual treatment and rehabilitation plan with their clients and give them a 2-day deadline to have the work completed. The individual treatment and rehabilitation plan on the list will be completed for the active clients no later then 8/30/2021 or sooner.
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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 two of three applicable client records reviewed.
Client # 5 was admitted on February 19, 2021 and was discharged on June 15, 2021. The individual treatment plan was completed on February 19, 2021 and an update was due no later than April 19, 2021; however, there was no update completed prior to discharge.
Client # 6 was admitted on December 2, 2020 and was discharged on June 7, 2021. The individual treatment plan was completed on December 29, 2020 and an update was due no later than February 29, 2021; however, there was no update completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will discuss with counselors every Friday during the clinical team meeting the significant of reviewing and updating their client treatment and rehabilitation plan and completing them within the 60 day required timeframe. The clinical supervisor will also conduct weekly chart audit before the team meeting identifying counselors who did not update their client treatment and rehabilitation plan. The clinical supervisor will then meet separately with each counselor after the meeting who have not updated treatment and rehabilitation plan with their clients and give them a 2-day deadline to have the work completed.
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