INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Men and Women for Human Excellence, Inc. was found to not 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to have a mechanism to collect feedback on completed trainings in two out of two staff for which it was required. Staff #1 was hired on 7/26/2010 as the Project Director for the facility and had no feedback forms documented in their staff record. Staff #2 was hired on 12/12/2016 as the Facility Director and had no feedback forms documented in their staff record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director shall ensure that MWFHE's mechanism to collect feedback on completed trainings is complied with. The personnel manager will review all completed trainings and ensure that a feedback form has been completed by the staff person who took the training. Completed feedback documents are to be maintained in the personnel file for Program Director's review. Feedback documents for trainings that were completed during the past year by Staff persons 1 and 2 has been placed in their files. Results of all reviews shall be forwarded to the Program Director. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on August 7, 2018 and an interview with the Project Director the facility failed to ensure that staff caseloads remained at or under 35:1.The findings include: The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on August 7, 2018. The form listed eight counselors, a clinical supervisor, a project director and a facility director as clinical staff . Based the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40, 37.5 or 35 as applicable), and the total number of clients assigned to the following employees on August 7, 2018, employee # 11, #5, # 7, # 6 and # 9 exceeded the allowable maximum 35:1 caseload.Counselor # 11 had an FTE caseload of 40:1Counselor # 5 had an FTE caseload of 40:1Counselor # 7 had an FTE caseload of 40:1Counselor # 6 had an FTE caseload of 40:1 Counselor # 9 had an FTE caseload of 50:1These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
MWFHE will ensure compliance with this standard. The Program Director with the Lead Counselor have reviewed each caseload of the identified counselors and have made adjustments so that each full-time counselor has 35 or less clients on their caseload. In addition to adjusting the caseloads in order to be in compliance, MWFHE has interviewed and hired another full-time counselor to provide services to clients that were removed from Counselor #11, 5,7,6, and 9 caseloads. The Lead Counselor will monitor the size of each caseload on a weekly basis and if noncompliance is indicted immediate action shall be taken to bring caseloads size into compliance. The Lead Counselor is to report all adjustments made to the Program Director. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room as it was observed that the group counseling room had a sheer curtain hanging over the window which allowed clients to be seen from the sidewalk outside. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MWFHE shall ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. The Executive Director is responsible for ensuring that this standard is fully complied with A new curtain is now in place in the group counseling room (9/10/18) that had a sheer curtain hanging over a window. The new curtain disallows clients from being seen from the sidewalk outside the group room thus ensuring confidentiality will be maintained. The Maintenance supervisor shall report any noncompliance observed during the regular in house inspection to the Executive director for corrective action. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
The facility failed to ventilate bathrooms by exhaust fan or window as the exhaust fan in the group counseling room's bathroom was non-operable. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MWFHE shall ensure compliance with this standard. A new exhaust fan was installed in the bathroom that had the defected one (9/10/18). The Executive Director shall receive ongoing reports from the maintenance supervisor to ensure ongoing compliance. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
The facility failed to to ensure that every fire extinguisher was inspected and approved annually by the local fire department or fire extinguisher company as the last time the extinguishers were inspected and approved was in October 2016.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MWFHE shall fully comply with this standard. On 8/10/18, all fire extinguishers were inspected and are now in full compliance. Updated tickets are on all fire extinguishers. The Maintenance supervisor shall document regular inspections and forward reports to the Executive Director. Yearly inspections are to be scheduled and performed by the Philadelphia Fire Company |
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
The facility failed to conduct an unannounced fire drill at least once a month. Additionally, the facility failed to prepare alternate exit routes to be used during fire drills. The facility failed to conduct unannounced fire drills during the months of November, December 2017, and January 2018. Also, every fire drill conducted used the front door as the exit route. These observations were based on the review of the fire drill logs for the time period of July 2017 through July 2018.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MWFHE shall fully comply with this standard. The Maintenance Supervisor shall oversee the conducting of monthly unannounced fire drills. Front and rear door exits are to be used when fire drills are conducted. Fire drill reports are to be completed following each drill and logged in the Fire Drill Log book. A report of each completed fire drill should be forwarded to the Executive Director to ensure compliance. |
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
The facility failed to ensure that treatment plans were reviewed and updated every sixty days. Client #1 was admitted on October 12, 2017 and was still active at the time of the investigation. The client had a treatment plan dated April 2, 2018 and the next was not due by June 2, 2018, however was not completed until June 4, 2018. Client #2 was admitted on January 29, 2018 and was still active at the time of the inspection. The client had a treatment plan dated February 15, 2018 and the next was due no later than April 15, 2018, however was not completed until April 29. 2018. The next treatment plan was due no later than June 29, 2018 however had not been completed as of the time of inspection. Client # 5 was admitted on November 28, 2017 and was discharged on May 4, 2018. The client had a treatment plan dated November 28, 2017 and the next was due no later than January 28, 2018, however was not in the client record as of the date of inspection. These findings wer reviewed with the facility staff during the licensing process.
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Plan of Correction
MWFHE shall fully comply with this standard. The Program Directed shall ensure compliance with this standard. All treatment plans shall be reviewed and updated at least every sixty days by primary therapist during regular counseling sessions and reviewed during supervision sessions. Also , any and all non-compliance with this standard indicated during QA reviews is to be promptly reported to the Program Director for immediate resolve. Clients #1, #2 and #5 Treatment plans are now in full compliance. Treatment Plan compliance is to be regularly monitor by the clinical supervisor. |