INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26, 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(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 received at least 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics training, within the regulatory time frame, in one of one applicable personnel record reviewed.
Employee #5 was hired as a counselor on May 30, 2023. The HIV/AIDS and TB/STD trainings were due to be completed no later than May 30, 2024; however, the trainings were not completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The lead counselor will ensure the new employee hired as a counselor on May 30, 2023 will be schedule no later then 10/30/2024 for The HIV/AIDS and TB/STD trainings and verification of certificate will be place in employee chart.
One of the condition of hiring new counselor at MWFHE have always been to provide proof of training including the 6 hours of HIV/AIDS and the 4 hours of tuberculosis, sexually transmitted diseases as required by regulatory agencies.
Moving forward , the director of program operations will ensure before hire that new D&A counselors provide verification of the HIV/AIDS and TB/STD training certificate in order to comply. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's February 2024 through May 2024 fire drill logs, the facility failed to document on the written fire drill record the number of persons in the facility at the time of the fire drill.
The fire drill log, dated May 27, 2024, did not include documentation of the number of persons in the facility at the time of the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The MWFHE Director of Programs Operation will conduct an in-service's training to staff on how to completed the fire drill log entirely after each fire drill is conducted no later then September 30, 2024.
The focus of the in-services training will be to ensure staff document on the fire drills form the number of persons in the facility at the time they are conducting the fire drill. Verification will be presented in the training sign-in sheet , training agenda, and documented on the upcoming monthly fire drills forms.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year. The facility had a financial audit exception which is now null and void due to 2022 reported earnings.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
MWFHE CEO will again apply/submit request to DDAP for a financial exemption waiver by August 15, 2024.
If the DDAP financial exemption waiver is not approved, then the CEO will become compliant by scheduling a 2022 Finacial external audit by December 30, 2024.
Steps the facility will take:
1. The CEO will ensure the 2024-2025 agency fiscal budget includes an external audit cost.
1. Call Mutiple External Auditing Companys to get a quote for the cost of the audit.
2. Select the lowest cost quote and then call to schedule a consultation
3. Select the date that the External auditing company has available to complete the audit.
4. If MWFHE Finacial external audit is not completed by the external audit company, then MWFHE will provide proof of services in process from the external auditing company during the next DDAP inspection.
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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 March 13, 2024 and was still active at the time of the inspection. The individual treatment plan, dated April 12, 2024, indicated the client was to receive individual counseling sessions once a month and group counseling sessions twice a month. There were no individual counseling or group counseling sessions documented during the month of May 2024.
Client # 6 was admitted on March 19, 2024 and was still active at the time of the inspection. The individual treatment plan, dated April 15, 2024, indicated the client was to receive individual counseling sessions once a month and group counseling sessions twice a month. There were no individual counseling or group counseling sessions documented during the month of May 2024.
Client # 7 was admitted on April 19, 2024 and was still active at the time of the inspection. The individual treatment plan, dated May 14, 2024, indicated the client was to receive individual counseling sessions twice a month and group counseling sessions twice a month. There was only one group counseling session documented during the month of May 2024.
This is a repeat citation from the July 6, 2022 and July 11, 2023 annual licensing renewal inspections, as well as the plan of correction follow-up inspection on February 9, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Primary Responsibility:
Counselor Responsibility: The primary responsibility for ensuring that all counseling sessions are documented will be placed on the assigned counselor. Counselors are required to complete and submit documentation for each session within 24 hours.
Lead Counselor Review:
The Lead Counselor will conduct weekly reviews of all client records to ensure that documentation is complete and accurate. Any discrepancies or missing documentation will be addressed immediately.
2. Training and Development:
Initial Training: All counselors will undergo mandatory training on proper documentation procedures and the importance of timely record-keeping. This training will be conducted by the Lead Counselor and will cover DDAP regulations, internal policies, and best practices.
Ongoing Training: Quarterly refresher training sessions will be conducted to reinforce documentation standards and address any emerging issues. These sessions will include case studies and practical exercises to ensure counselors are fully equipped to maintain compliance.
Enhanced Monitoring and Auditing:
Internal Audits: Bi-weekly internal audits will be conducted by the compliance team to review client records and ensure adherence to documentation requirements. The results of these audits will be reported to the Lead Counselor and Program Director.
Manual Tracking System: A manual tracking system will be implemented to monitor the completion of counseling sessions and documentation in real-time. This system will involve the use of paper charts and email notifications.
Manual Tracking System Breakdown
1. System Components:
● Paper Charts: Counselors will continue to use paper charts to document all individual and group counseling sessions. These charts will be reviewed weekly by the Lead Counselor.
● Email Notifications: The Lead Counselor will send weekly email notifications to counselors, listing clients who have clinical documentation due. This will ensure that counselors are aware of upcoming deadlines and can prioritize their documentation tasks.
2. Key Features:
● Weekly Reviews: The Lead Counselor will review all paper charts on a weekly basis to ensure that documentation is complete and accurate.
● Email Alerts: Counselors will receive weekly email alerts with the names of clients who have clinical documentation due. These alerts will serve as reminders to complete and submit documentation promptly.
● Compliance Reporting: The compliance team will generate bi-weekly reports on the status of client documentation, highlighting any issues or discrepancies. These reports will be reviewed by the Lead Counselor and Program Director.
● Audit Trail: A detailed audit trail will be maintained, recording all actions taken within the system to ensure transparency and accountability.
3. Implementation Plan:
● Phase 1: Setup and Training (1 month):
○ Develop a standardized template for paper charts to ensure consistency in documentation.
○ Train counselors on the use of the manual tracking system and email notification process.
● Phase 2: Rollout and Monitoring (2 months):
○ Implement the manual tracking system and begin sending weekly email notifications.
○ Monitor the system's effectiveness and address any issues or gaps identified during the initial rollout.
● Phase 3: Continuous Improvement (Ongoing):
○ Regularly review and update the manual tracking system based on feedback from staff and findings from compliance audits.
○ Conduct ongoing training sessions to reinforce best practices and address any emerging issues.
4. Accountability Measures:
○ Performance Reviews: Counselors' adherence to documentation requirements will be included in their performance reviews. Repeated failure to comply with documentation standards will result in corrective actions, including additional training or disciplinary measures.
○ Client Feedback: Regular feedback will be solicited from clients regarding their counseling sessions to ensure that services are being provided as planned. This feedback will be reviewed during internal audits.
5. Documentation and Compliance Checks:
○ Documentation Protocols: Clear protocols will be established for documenting individual and group counseling sessions. These protocols will be communicated to all counseling staff and included in the training materials.
Statement of Compliance
The MWFHE assures that counseling services are provided according to the individual treatment and rehabilitation plan for each client. We have reviewed the findings and provide the following response to clarify and address the observations.
Observations and Responses
Observation: Client #7
● Admitted on: April 19, 2024
● Observation: Only one group counseling session documented during May 2024.
Response: Based on DDAP findings, Client #7 had one group note and two individual sessions documented for the month of May, thus meeting the treatment attendance requirement of three sessions per month as outlined in the individual treatment and rehabilitation plan. Our records confirm the following:
● Group Counseling Session: Completed and documented.
● Individual Counseling Sessions: Two sessions completed and documented.
We will review our documentation process to ensure that all sessions are accurately recorded and easily accessible for review during inspections.
Corrective Actions Taken
1. Documentation Review:
We have conducted a thorough review of our documentation procedures to ensure that all counseling sessions are recorded accurately and timely. This will include regular audits and reviews to maintain compliance.
2. Staff Training:
All counseling staff will undergo additional training on the importance of timely and accurate documentation. This training will be conducted quarterly to reinforce best practices.
3. Internal Monitoring:
An enhanced internal monitoring system has been implemented to track the documentation of counseling sessions. Alerts will be generated for any missing entries to ensure prompt follow-up.
4. Compliance Audits:
Regular compliance audits will be conducted to ensure adherence to DDAP regulations. These audits will include a review of client records to verify that all required sessions are documented.
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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 a maintain a complete client record on an individual, which is to include case consultation notes, in two of two applicable client records reviewed.
Client #3 was admitted on March 13, 2024 and was active at the time of inspection. There was no documentation, in the record, of a case consultation being completed at the time of the inspection.
Client #6 was admitted on March 19, 2024 and was active at the time of inspection. There was no documentation, in the record, of a case consultation being completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Immediate Actions:
● The counselor will complete and document case consultation notes for Clients #3 and #6 immediately.
● The Lead Counselor will review these notes for accuracy and completeness.
2. Systematic Changes:
● A new protocol will be established where case consultations are conducted and documented within 30 days of client admission and subsequently every 90 days.
● Training for all counselors on this protocol will be conducted by July 20, 2024.
3. Monitoring and Oversight:
● The Lead Counselor will audit client records monthly to ensure all required documentation, including case consultation notes, is complete and accurate.
● Any deficiencies found during these audits will be addressed immediately with additional training or corrective actions as necessary.
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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 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, as well as the plan of correction follow-up inspection on February 9, 2024. 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 June 26, 2024 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How MWFHE plans on following all plans of correction going forward
The CEO will ensure the 2024-2025 agency fiscal budget includes an external audit cost by 2025.
1. MWFHE CEO will again apply/submit request to DDAP for a financial exemption waiver by August 15, 2024.
2. If the DDAP financial exemption waiver is not approved, then the CEO will become compliant by scheduling a 2022 Financial external audit by December 30, 2024.
The Lead Counselor will conduct weekly reviews of all client records to ensure that clinical documentation is complete in the timeframe and accurate including treatment plan and case consultation. Any discrepancies or missing documentation will be addressed immediately.
Steps
1. Training and Development:
Initial Training: All counselors will undergo mandatory training on proper documentation procedures and the importance of timely record-keeping. This training will be conducted by the Lead Counselor and will cover DDAP regulations, internal policies, and best practices.
2. Email Notifications: The Lead Counselor will send weekly email notifications to counselors, listing clients who have clinical documentation due. This will ensure that counselors are aware of upcoming deadlines and can prioritize their documentation tasks.
3. The Lead counselor will ensure a new protocol will be established where case consultations are conducted and documented within 30 days of client admission and subsequently every 90 days.
4. Training for all counselors on this protocol will be conducted by July 20, 2024.
Moving forward MWFHE will continue to improve and adhere to DDAP plan of corrections in order to maintain DDAP regulatory standards.
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