INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 6-7, 2010 licensure renewal inspection. The follow-up inspection was conducted on September 7, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Men & Women For Human Excellence 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 October 13, 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 a review of personnel records and an interview with the clinical director, the facility failed to document the qualifications for the position of counselor in two of two personnel records.
The findings include:
Two personnel records were reviewed and an interview with the clinical director occurred on September 7, 2010. The facility did not provide verification of the qualifications for two counselors. The clinical director was unable to confirm whether verification of the qualifications for personnel # 1 and 2 had been obtained.
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Plan of Correction
The Clinical Director will meet with (has met with) both personnel # 1 and personnel # 2 and request from each of them an official transcript attesting to their educational qualifications as counselors. Such documents are to be provided directly to the clinical director. The Clinical Director will ensure that new prospective clinical hires provide verification of their qualifications prior to their first day of employment. |
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
At the time of follow-up review, on September 7, 2010, it was not possible for the licensing specialist to determine if the facility followed the original plan of correction and was in compliance due to the fact that the 2010 training year is still in progress, and the annual training requirements for the project/facility director are not yet due.
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Plan of Correction
The Clinical Director (hired, July 26, 2010) will provide documentation for at least 12 clock hours of training by 12/31/2010. The Executive Director will ensure, via review of personnel files, annually) that at least 12 clock hours of training for the Clinical Director is obtained for the current training period (and annually thereafter) and documented. |
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 an interview with the clinical 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:
An interview with the clinical director was conducted on September 7, 2010. The clinical director was unable to provide a written letter of agreement with a licensed hospital or physician for 24-hour emergency medical coverage. The clinical director was unable to confirm whether a letter of agreement with a licensed hospital or physician had been obtained.
This is a repeat deficiency. The facility was cited at the 04/14/09 licensing inspection, the 12/04/09 follow-up inspection, the 04/07/10 licensing inspection, and remains out of compliance as of the 09/07/10 follow-up inspection.
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Plan of Correction
The Clinical Director requested, received, and documented a written letter of agreement with a licensed hospital for 24-hour emergency medical coverage. The Clinical Director will ensure, via annual review of the Drug and Alcohol Manual, that a current written letter of agreement is maintained. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on an interview with the Clinical 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:
An interview with the Clinical Director was conducted on September 7, 2010. The Clinical Director was unable to provide an annual audit of financial activities for the facility's January -December 2008 fiscal year which was cited during 04/07/10 Licensing Inspection nor the January - December 2009 fiscal year which was due at the time of the follow-up inspection.
When asked, the Clinical Director was unable to confirm whether a financial audit had been completed for the facility's January -December 2008 and/or the January - December 2009 fiscal year.
The facility was previously cited for failure to provide copies of independent financial audits during the 4/14/09 and 04/07/10 Licensing Inspections.
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Plan of Correction
The Clinical Director will confer with the Executive Director and request that an independent annual audit of financial activities for the facility's January-December 2008 and/or December 2009 fiscal year be made available in time for the next Licensing Inspection. Upon completion of such documents, the Clinical Director will provide copies to Licensing Inspection for review. Also, an annual copy of an independent financial audits is to be completed and maintained by the Executive Director and will be made available upon request. |
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 and an interview with the clinical director, the facility failed to document a psychosocial evaluation in eleven of eleven client records.
The findings include:
Eleven client records were reviewed and an interview with the clinical director occurred on September 7, 2010. The clinical director stated the facility ' s policy requires a psychosocial evaluation to be completed within 30 days after admission for all clients. The facility did not document a psychosocial evaluation, as per facility policy, in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11.
The admission date for client #1 was 5/28/10, a psychosocial evaluation was due no later than June 27, 2010; however it was not documented at the time of review on 9/7/10.
The admission date for client #2 was 8/5/10, a psychosocial evaluation was due no later than September 4, 2010; however it was not documented at the time of review on 9/7/10.
The admission date for client #3 was 8/6/10, a psychosocial evaluation was due no later than September 5, 2010; however it was not documented at the time of review on 9/7/10.
The admission date for client #4 was 8/4/10, a psychosocial evaluation was due no later than September 3, 2010; however it was not documented at the time of review on 9/7/10.
The admission date for client #5 was 7/26/10, a psychosocial evaluation was due no later than August 25, 2010; however it was not documented at the time of review on 9/7/10.
The admission date for client #6 was 6/3/10, but the psychosocial evaluation was not dated or signed. Additionally, the psychosocial evaluation did not provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client ' s current situation.
The admission date for client #7 was 6/3/10, but the psychosocial evaluation was not dated or signed. Additionally, the psychosocial evaluation did not provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client ' s current situation.
The admission date for client #8 was 5/3/10, but the psychosocial evaluation was not dated or signed. Additionally, the psychosocial evaluation did not provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client ' s current situation.
The admission date for client #9 was 7/23/10, but the psychosocial evaluation dated 5/26/10 did not provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client ' s current situation.
The admission date for client #10 was 7/16/10, but the psychosocial evaluation was not dated or signed. Additionally, the psychosocial evaluation did not provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client ' s current situation.
The admission date for client #11 was 6/3/10, but the psychosocial evaluation was not dated or signed. Additionally, the psychosocial evaluation did not provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client ' s current situation.
This is a repeat deficiency. The facility was cited at the 04/14/09 licensing inspection, the 12/04/09 follow-up inspection, the 04/07/10 licensing inspection, and remains out of compliance as of the 09/07/10 follow-up inspection.
The original POC for the 04/07/10 licensing inspection stated:
"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 [sic]. 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 [sic]."
The completion date was to be 7/30/10.
The Facility Director confirmed the findings.
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Plan of Correction
The Clinical Director will review, with all clinical staff, the facility's policy that requires a psychosocial evaluation to be completed within 30 days after admission for all clients. All such reviews are to be documented. Compliance of this policy will be monitored via bi-weekly chart audits, by the Clinical Supervisor. If psychosocial evaluations have not been completed by the 23rd day, the primary therapist will be alerted and instructed to complete it within the following six days at which time the clinical supervisor will audit the identified chart again. If the psychosocial is not completed by day 29, the clinical supervisor will direct the primary therapist, assigned to the case, to complete it. The clinical supervisor is to report non-compliance of this policy to the clinical director for review and possibly further action if warranted. Also, the Clinical Director will provide mandatory trainings for all clinical staff on the appropriate method of completing psychosocial evaluations. Trainings will take place during weekly scheduled staff meetings. The Clinical Supervisor will be responsible for conducting bi-weekly chart reviews to determine if newly acquired knowledge is being applied. In client records # 1, 2, 3, 4 and 5, psychosocial evaluations have been completed. In client records # 6, 7, and 8, dates and signatures has been affixed to the psychosocial evaluations. Additionally, the psychosocial evaluations now provide a composite picture of the individuals in relationship to the collected historical information. In client record # 9, a psychosocial evaluation has been completed and now provides a composite picture of the individual in relationship to the collected historical information. In client records # 10 and 11, the dates and signatures are now affixed to the psychosocial evaluations. Additionally, the psychosocial evaluations now provide a composite picture of the individuals in relationship to the collected historical information. |
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 and an interview with the clinical director, the facility failed to document a treatment plan in seven of eleven client records.
The findings include:
Eleven client records were reviewed and an interview with the clinical director occurred on September 7, 2010. The clinical director stated the facility ' s policy requires a comprehensive treatment plan to be completed within 30 days after admission for all clients. The facility did not document a comprehensive treatment plan, as per facility policy, in client records # 2, 3, 4, 5, 9, 10 and 11.
The admission date for client #2 was 8/5/10, a treatment plan was due no later than September 4, 2010; however it was not documented at the time of review on 9/7/10.
The admission date for client #3 was 8/6/10, a treatment plan was due no later than September 5, 2010; however it was not documented at the time of review on 9/7/10.
The admission date for client #4 was 8/4/10, a treatment plan was due no later than September 3, 2010; however it was not documented at the time of review on 9/7/10.
The admission date for client #5 was 7/26/10, a treatment plan was due no later than August 25, 2010; however it was not documented at the time of review on 9/7/10.
The admission date for client #9 was 7/23/10, a treatment plan was due no later than August 22, 2010; however it was not documented at the time of review on 9/7/10.
The admission date for client #10 was 7/16/10, a treatment plan was due no later than August 15, 2010; however it was not documented at the time of review on 9/7/10.
The admission date for client #11 was 6/3/10, a treatment plan was due no later than July 3, 2010; however it was not documented at the time of review on 9/7/10.
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Plan of Correction
The Clinical Director has met with the clinical supervisor and the primary therapists assigned to client records # 2, 3, 4, 5, 9, 10, and 11 and instructed each therapist to complete the treatment plans that are past due during their next session with identified clients. The Clinical Director and Clinical Supervisor will audit the identified charts, bi-weekly, to ensure and confirm compliance. Also, the Clinical Director will review policy, during weekly staff meetings, with all clinical staff about completing treatment plans in a timely manner. Such review and/or training shall be documented. The Clinical Supervisor will conduct bi-weekly chart audits to ensure ongoing compliance. |
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 a review of client records, the facility failed to document a case consultation in four of four client records.
The findings include:
Eleven client records were reviewed on September 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 # 1, 6, 7 and 8.
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.
The admission date for client #1 was 5/28/10, but a case consultation was not documented at the time of review on 9/7/10.
The admission date for client #6 was 6/3/10, but a case consultation was not documented at the time of review on 9/7/10.
The admission date for client #7 was 6/3/10, but a case consultation was not documented at the time of review on 9/7/10.
The admission date for client #8 was 5/3/10, but a case consultation was not documented at the time of review on 9/7/10.
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Plan of Correction
The Clinical Director met with the clinical supervisor and the primary therapists of the four identified client records, #1, 6, 7, and 8 and instructed each therapist to present each client for case consultation during the weekly clinical staff meetings. The clinical supervisor and the respective therapist will document all such case consultations. Also, the Clinical Director and Clinical Supervisor will conduct bi-monthly chart reviews to determine and confirm ongoing compliance with respect to the timely completion of case consultations. |