INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 6-7, 2010 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 and a plan of correction is due on May 11, 2010.
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Plan of Correction
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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 the review of personnel records and an interview with the project/facility director, the facility failed to document the qualifications for the position of counselor in two of four personnel records.
The findings include:
Six personnel records were reviewed on April 6, 2010. Of the six records reviewed, four were identified as counselors, but the qualifications for this position were not included in personnel records # 4 and 5.
Personnel record # 4 documented a bachelor ' s degree, but the diploma did not indicate if the major was in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or another related field.
Personnel record # 5 documented a master ' s degree, but the diploma did not indicate if the major was in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or another related field.
An interview with the project/facility director was conducted on April 7, 2010. The project/facility director confirmed that personnel records # 4 and 5 did not include verification of their qualifications.
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Plan of Correction
The Clinical Superviser will review all new hire's for counselor qualification before hire to ensure the new employees have the correct information. This information will include a degree in the related field such as medicine, chemical dependency, nursing, social work on the diploma. Also during the hiring process the clinical supervisor will obtain for new hire's documentation of qualifications. If the diploma does not include the related field a transcript will also be required. Clinical Supervisor will ensure that employees #s 4 and 5 will obtain qualifications for employement by July 20, 2010. |
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 the review of personnel records and an interview with the project/facility director, the facility failed to document at least 12 clock hours of training annually for project directors and facility directors in one of one personnel records.
The findings include:
Six personnel records were reviewed on April 6, 2010. Of the six records reviewed, one was identified as the project/facility director and was required to complete at least 12 hours of training annually. The facility did not document at least 12 clock hours of training for the 2009 training year in personnel record # 1.
Personnel record # 1 documented 0 hours of training for the 2009 training year.
The project/facility director confirmed that he had not completed twelve hours of training for the 2009 training year.
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Plan of Correction
MWFHE, Inc. will ensure the its Project/Facility Director complete the required 12 clock hours per year. MWFHE, Inc. Clinical Superviser will be directly responsbile for ensuring that Project/Facility Director clock hours are completed and recorded. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document fire extinguisher training in one of six personnel records.
The findings include:
Six personnel records were reviewed on April 6, 2010. All six records required documentation of fire extinguisher training within seven days from the date of hire. The facility did not document fire extinguisher training within seven days of hire in personnel record # 4.
Personnel # 4 was hired on 2/15/10, but the employee orientation checklist indicated this training occurred on 3/5/10.
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Plan of Correction
MWFHE,Inc. Clinical Supervisor will ensure that all new hires complete the agency's extingusiher training within the seven day period upon hire. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to document training to perform assigned task during emergencies in one of six personnel records.
The findings include:
Six personnel records were reviewed on April 6, 2010. All six records required documentation of emergency training within seven days from the date of hire. The facility did not document emergency training within seven days of hire in personnel record # 4.
Personnel # 4 was hired on 2/15/10, but the employee orientation checklist indicated this training occurred on 3/5/10.
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Plan of Correction
The Clinical Supervisor will ensure that all new hires complete the agency's emergency training within the first seven days of hire. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on an interview with the project/facility director, and a review of the facility ' s policy manual and client records, the facility failed to develop written procedures for the management of treatment services.
The findings include:
On April 6-7, 2010, an interview with the project/facility director was conducted and the facility ' s policy manual and eleven client records were reviewed. The facility did not develop written procedures for the management of treatment services that were consistent with their practice.
The facility ' s policy titled " Admission Procedure " states:
2. Assessment Evaluation (Initial Visit) - During initial session, the following forms are to be completed, signed and dated by the intake counselor doing the initial evaluation:
(a)Complete Referral/Intake and Diagnostic Form, If appropriate.
(b)Complete the Psychosocial Assessment or Comprehensive Biopsychosocial Evaluation (CBE) and note appropriateness via the DSM-IV criteria for psychoactive substances. If a prior evaluation has been completed by another licensed drug and alcohol agency within the last 60 days and is being obtained through signed release authorizations the counselor and the client should focus on that information and the dimensional criteria in the clinical interview. The review of any and all information forwarded from another agency will be documented in the client file.
The facility did not document a psychosocial evaluation during the initial session in client records # 1, 2, 3, 4, 5, 6, 7 8, 9, 10 and 11.
The project/facility director stated their actual practice is to complete the psychosocial evaluation within thirty days after admission.
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Plan of Correction
The Project Director will review the agency's policy on "Admission Procedure" and make corrections to the Admission Procedure policy to ensure that an accurate time frame is put in place which will allow time for agency's counselors to complete the Admission Procedure. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on the review of the facility ' s letters of agreement and an interview with the project/facility director, the facility failed to document a written letter of agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
The findings include:
The facility ' s written letters of agreement were reviewed, and an interview with the facility director was conducted on April 6, 2010. The facility did not have a written agreement for 24-hour emergency medical coverage. The project/facility director confirmed that a letter of agreement with a licensed hospital or physician had not been obtained.
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Plan of Correction
The Project Director will continue to address the issue of MWFHE not having a 24-hour emergency medical coverage agreement with a licensed hospital or physician. The Project Director's next plan of action is to contract with a 24-hour on-call physician. MWFHE plans to have this agreement in place within 30-days. |
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 the review of administrative documentation and an interview with the project/facility director, the facility failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility ' s administrative documentation was reviewed and an interview with the project/facility director was conducted on April 6, 2010. The facility was required to document an annual audit of financial activities. The facility did not document a financial audit for the 2007-2008 fiscal year. The project/facility director confirmed that a financial audit had not been completed.
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Plan of Correction
The Project Director will address this issue to ensure that MWFHE, INc. have on-hand its independent annual audit of its financial activitites for review by The Department of Health. The Project Director will employ an independent auditing firm to perform MWFHE, INc. annual independent audit. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to document informed and voluntary consent from the client for the disclosure of information contained in seven of eleven client records.
The findings include:
Eleven client records were reviewed on April 6, 2010. All eleven records required documentation of informed and voluntary consent. The facility did not document a Qualified Service Organization Agreement or a signed consent for the release of client information to a laboratory in client records # 1, 2, 3, 5, 6, 7 and 8.
Client records # 1, 2, 3, 5, 6, 7 and 8 included correspondence with a laboratory, but informed and voluntary consent from the client was not documented.
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Plan of Correction
The Clinical Supervisor will review all client's records at least once per month to ensure that all client's have voluntary consent forms signed and dated by both the client and a staff person. Voluntary consent forms for laboratory has been addressed and consent forms are being presented to all clients to be signed and dated by both clinet and staff. |
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 the review of client records, the facility failed to document a psychosocial evaluation in nine of nine client records.
The findings include:
Eleven client records were reviewed on April 7, 2010. Of the eleven records reviewed, psychosocial evaluations were required in nine. The facility did not document a psychosocial evaluation in client records # 1, 2, 3, 4, 5, 6, 7, 8 and 9.
The facility did not document a psychosocial evaluation to include the client ' s needs or problems that can or cannot be resolved through treatment or that might inhibit treatment in client records # 1, 2, 3, 4, 5, 6, 8 and 9.
The facility did not document a psychosocial evaluation to include the client ' s negative factors that might affect treatment in client records # 1, 3, 4 and 9.
The facility did not document a psychosocial evaluation to include the client ' s assets/strengths that can contribute to the resolution of identified problems in client records # 1, 3, 4 and 9.
The facility did not document a psychosocial evaluation to include the client ' s preferred coping mechanisms in client records # 1, 3, 4, 5, 7, 8 and 9.
The facility did not document a psychosocial evaluation to include the potential or available client support systems in client records # 1, 2, 3, 4, 5, 6, 7, 8 and 9.
The facility did not document a psychosocial evaluation to include conclusions regarding the client ' s attitude toward and ability to participate in the treatment process in client records # 1, 2, 4, 5, 7, 8 and 9.
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Plan of Correction
MWFHE, Inc. will began training with its staff on psychosocial evaluations. Within the training MWFHE, Inc. will address how to document in its psychosocial evaluations, client's needs and problems, assets/strengths,coping mechanisms,potential or available support and attitude toward and ability to participate in treatament. The Clinical Supervisor will conduct random chart audits on a monthly basis after the trainings have been completed to ensure that psychosocial evaluations are completed proplerly. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document a treatment plan to include type and frequency of treatment and rehabilitation services in five of seven client records.
The findings include:
Eleven client records were reviewed on April 7, 2010. Of the eleven records reviewed, seven required treatment plans to include type and frequency of treatment and rehabilitation services. The facility did not document type and frequency of treatment and rehabilitation services on treatment plans as per facility policy in client records # 1, 2, 5, 6, and 7.
The facility policy titled " Treatment Planning " states:
The Treatment Plan will be completed on the Men and Women for Human Excellence Inc. ' s Treatment Plan Form and Will Include:
a.Client ' s Name
b.Program
c.Problem Statement
d.Short Term Goal
e.Objectives
f.Date Objective was established
g.Provider
h.Frequency of Methods
i.Due Date
j.Outcome
In client record # 1, the treatment plan documented on 12/9/09 did not include type and frequency of treatment and rehabilitation services.
In client record # 2, the treatment plan documented on 10/30/09 did not include type and frequency of treatment and rehabilitation services.
In client record # 5, the treatment plan documented on 12/18/09 did not include type and frequency of treatment and rehabilitation services.
In client record # 6, the treatment plan documented on 12/31/09 did not include type and frequency of treatment and rehabilitation services.
In client record # 7, the treatment plan documented on 12/22/09 did not include type and frequency of treatment and rehabilitation services.
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Plan of Correction
MWFHE, Inc. will include in its treatment plans an area for "Frequency of Treatment" and "Rehabilitation Services". MWFHE will provide trainings to its staff on how to complete such sections. The Clinical Supervisor will perform random chart audits on a monthly basis to ensure that the such areas of concerns are being completetd properly. |
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 the review of client records, the facility failed to document a treatment plan update in three of four client records.
The findings include:
Eleven client records were reviewed on April 7, 2010. Of the eleven records reviewed, four required treatment plan updates. The facility did not document a treatment plan update to include an assessment of progress as per facility policy in client records # 1, 2 and 5.
The facility's policy titled " Treatment Planning " states:
Outpatient Treatment Plans will be reviewed and updated, by the client ' s primary counselor, every sixty days following the development of the previous treatment plan.
If the client was admitted to the Intensive Outpatient Program, the treatment plan will be updated every thirty days from the date of the initial treatment plan.
These reviews/updates are noted on the Treatment Plan Review/Update Form. Information regarding progress in areas or concerns is noted on the forms.
In client record # 1, the treatment plan was documented on 12/9/09, but the treatment plan update documented on 2/9/09 did not include an assessment of progress.
In client record # 2, the treatment plan was documented on 10/30/09, but the treatment plan updates documented on 1/14/10 and 3/14/10 did not include an assessment of progress.
In client record # 5, the treatment plan was documented on 12/18/09, but the treatment plan update documented on 2/17/09 did not include an assessment of progress.
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Plan of Correction
MWFHE will began provide trainings for its staff on treatment planning. After the completions of the training the Clinical Supervisor will perform randon chart audits on a monthly basis to ensure that treatment plans are being completed on time. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document a case consultation in two of four client records.
The findings include:
Eleven client records were reviewed on April 7, 2010. Of the eleven records reviewed, four required documentation of a case consultation. The facility did not document a case consultation at least every ninety days, as per facility policy, in client records # 2 and 6.
The facility ' s policy titled " Case Consultation (Reviews) " states:
Men and Women for Human Excellence Inc. program has developed procedures for the ongoing review of cases as an example of its commitment to quality care and its belief in the team approach to treatment. All active cases will be reviewed at a minimum of every ninety days if the client was admitted to the program.
Client # 2 was admitted to the program on 10/6/09, but a case consultation was not documented at the time of review on 4/7/10.
Client # 2 was admitted to the program on 12/2/09, but a case consultation was not documented at the time of review on 4/7/10.
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Plan of Correction
Clinical Supervisor reviews all client's charts monthly to ensure that all documention, which includes "CAse Consultation" are done on time every 90-days. The Clinical Supervisor will again review charts to ensure that this process is being completed. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records and an interview with the project/facility director, the facility failed to document follow-up information in one of one client records.
The findings include:
Eleven client records were reviewed on April 7, 2010. Of the eleven records reviewed, one required documentation of follow-up information. The facility did not document follow-up information within 30 days from the date of discharge, as per facility policy, in client record # 7.
The facility ' s policy titled " Referral/Follow-up " states:
It is the policy of Men and Women for Human Excellence Inc. to follow-up on all clients who have successfully or unsuccessfully completed the program. Follow-up occurs within 30, 60 and 90 days following discharge, by the Primary Counselor, and may be done through an individual session, follow-up phone conversation, or via client and/or family follow-up program evaluations. Sessions or phone calls are logged into the client ' s record.
Client # 7 was admitted to the program on 12/30/09 and discharged on 2/11/10, but follow-up was not documented at the time of review on 4/7/10.
An interview with the project/facility director was conducted on April 7, 2010. The project/facility director confirmed that follow-up was not documented in client record # 7.
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Plan of Correction
Clincial Supervisor will began reviewing all discharged charts to ensure that MWFHE follow-up process is being completed. The process is that discharged follow-ups occurs every 30, 60, and 90 days after discharge date by the primary counselor, either by phone contact, individual session or letter, all individual sessions and phone calls are to be logged. The clinical supervisor will follow this process. |