INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 13 and 14, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Men and 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 12, 2009.
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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 and training records on April 13, 2009, the facility failed to document that counselors and counselor assistants completed a minimum of 6 hours of HIV/Aids and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training within the first year of employment and/or that other staff and volunteers completed the training within two years of employment.
Findings:
Eight personnel and training records were reviewed on April 13, 2009. Three out of eight personnel records lacked documentation to verify that the mandatory training was completed within the required timeframe.
The facility failed to document a minimum of 6 hours of HIV/Aids training for employee #7 as of the ending date of this licensing inspection. Employee #7 was hired in August 2004.
The facility failed to document at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training as of the ending date of this licensing inspection for employees #2 and 5. Employee #2 was hired in July 2007. Employee #5 was hired on March 6, 2008.
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Plan of Correction
Clinical Director has contacted BEBASHI/Phildelphia Fight to facilitate training on HIV/AIDS and STD's for staff. BEBASHI has responded by agreeing to do the trainings by 7/1/09.
Clinical Director will ensure that all mandatory trainings are completed with in required time frame. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and training records, the facility failed to ensure that at least one person trained in CPR and first aid was onsite during the project's hours of operation.
Findings:
Personnel and CPR certification and first aid training records were reviewed on April 13 and 14, 2009. At least one person trained in CPR and first aid was required between the hours of 9 AM and 8 PM. Based on the documentation provided by the facility, the facility failed to ensure that at least one person trained in CPR and first aid was onsite during the hours of operation. The facility did not provide documentation that any staff working the evening hours were trained in CPR and first aid.
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Plan of Correction
Clinical Director has acquired the training services of a Red Cross Certified Instructor to conduct First Aid and CPR Training to requisite staff by 7/1/09. Clinical Director is responsible for ensuring during hours of operation a certified staff member in CPR/First Aid will be present.
Clinical Director has also acquired the training services of a Certified Physician's Assistant to conduct training on Tuberculosis for the staff by 8/1/09.
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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 a review of the letters of agreement, the facility failed to document a written agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
Findings:
The letters of agreement were reviewed on April 13, 2009. A written agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage was required. The facility failed to document a written agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
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Plan of Correction
Clinical Director has contacted Episcopal Hospital of Philadephia an affiliate of the Temple University Hospital System to enter into a written agreement to provide necessary coverage (24 hours)in the event that a consumer may need medical attention.
MWFHE,Inc. maintains a written agreement with Fairmount Behavioral Health to provide necessary psychiatric coverage. |
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 a review of administrative documents, the facility failed to document an annual audit of financial activities associated with the project's drug/alcohol abuse services completed within six months of the end of the fiscal year.
Findings:
The annual audit for Fiscal Year 2007 was reviewed on April 13, 2009. The facility failed to document that the annual audit of financial activities for Fiscal Year 2007 was completed within six months of the end of the fiscal year. Fiscal Year 2007 ended 12/31/07 and the audit was not completed until 4/13/09.
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Plan of Correction
Executive Director will be responsible to ensure that the Accountant provides an annual audit within a 6 month period from the end of Fiscal Year ending each 12/31. |
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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in seven of seven client records reviewed. The facility also used consents to release information forms which contained "I understand that it is possible that information used or disclosed pursuant to this authorization my be redisclosed by the recipient and no longer may be subject to privacy protections provided by law" in seven of seven client records reviewed. Additionally, the facility's HIPAA form signed by the clients allowed for the release of protected information without the written consent of the clients. The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to Adult Probation and Family Court.
Findings:
Seven client records were reviewed on April 14, 2009. Informed and voluntary consents were required in seven client records. The facility did not document a Qualified Service Organization Agreement with Atlantic Labs or Princeton Labs. The facility did not have written consents for disclosure to these labs in client records #1, 2, 3, 4, 5, 6 and 7. The facility had clients sign their HIPAA form which did not allow for the release of information according to 255.5 Pa Code regulations for clients #1, 2, 3, 4, 5, 6 and 7. The consents to release information signed by clients allowed for the redisclosure of information in client records #1, 2, 3, 4, 5, 6 and 7. The facility failed to obtain an informed and voluntary consent to release information as the facility released information to Family Court without a signed consent for client #4 and the facility released information to Adult Probation with no consent in client record #2.
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Plan of Correction
Clinical Director will contact partcipating LAB to ensure that MWFHE, INC., obtains a qualified service organization agreement by August 31, 2009
In addition, the clinical director has revised existing HIPPA Confidentialty Authorization Form. The first change to the document will be the "Omittance" of the following statement, " I understand that it is possible that information used or disclosed pursuant to this authorization be redisclosed by the recipient and no longer may be subject to privacy protections provided by law." Secondly, the Acknowledgment Form used by MWFHE, Inc. attesting to the receipt, review, and understanding of Information Privacy Notice regarding the disclosure of confidential information for the purpose of treatment,now incorporates a statement that gives "consumer consent" to release this confidential information.Clinical supervisor will ensure that consumers have all neccesary and appropriate consents completed during intake process and throughout the course of treatment. A separate consent will be completed for the release of pertinent information as needed for each entity involved in the consumer's treatment. (i.e.,legal system, family court, etc.) The Clinical supervisor will review records monthly to ensure that appropriate consents are signed by consumer for the purposes of treatment.
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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, the facility failed to document a psychosocial evaluation to include client problems/needs, assets/strengths, support systems,coping mechanisms, negative factors, attitude toward treatment and/or the counselor's conclusions/impressions in six of seven client records reviewed. The facility also failed to document any psychosocial evaluation for one of seven client records reviewed.
Findings:
Seven client records were reviewed on April 14, 2009. Psychosocial evaluations were required in seven client records. The facility did not document a psychosocial evaluation in client records # 1, 2, 3, 4, 5, 6 and 7.
The facility did not document a psychosocial evaluation to include the client ' s assets/strengths in client records #1, 3, 4, 6 and 7.
The facility did not document a psychosocial evaluation to include the client ' s support systems in client records # 1, 2, 3, 4, 6 and 7.
The facility did not document a psychosocial evaluation to include the client ' s coping mechanisms in client records # 1, 3, 4, 6 and 7.
The facility did not document a psychosocial evaluation to include the client ' s negative factors in client records # 2, 3, 4, 6, 7 and 8.
The facility did not document a psychosocial evaluation to include the client's attitude toward treatment in client records #1, 2, 3, 4, 6 and 7.
The facility did not document a psychosocial evaluation to include conclusions regarding the client ' s attitude towards and ability to participate in treatment in client records # 1, 2, 3, 4, 6, 7 and 8.
The facility did not document any psychosocial evaluation in client record #5.
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Plan of Correction
Training will be conducted by the Behavioral Health Consultant on July, 10, 2009 during which time all clinical staff will be instructed on approriate clinical information gathering. Clinical Director will ensure that training is conducted on July 10, 2009, and that all clinical staff is present.
Charts will be audited once a month by the Clinical Supervisor to ensure that the pscyhosocial document is completed, signed-off, and placed in consumer's chart |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include proposed types of supportive services in four of seven client records.
Findings:
Seven client records were reviewed on April 14, 2009. Treatment plans with proposed types of supportive services were required in seven client records. The facility did not document treatment plans with proposed types of supportive services in client records #1. 3, 5 and 7.
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Plan of Correction
Clinical Director will develop and implement a new treatment plan form that will encompass the missing requisite information such as supportive services.
A newly developed treatment plan has been constructed. Information necessary to meet clicical standards have been incorprated in the new document.
Training on the new forms was conducted by a Behavioral Health Consultant on May 29th the new form was implemented today June 1, 2009.
The newly devised Comprehensive, and
Updated Treatment plan forms will now denote progression/regression of consumer during treatment plan period, completed goals or incompleted goals that require carrying over to new treatment plan period, consumer strengths,obstacles that may impede treatment process.
The Clinical Supervisor will ensure that all treatment plans are completed and signed. Charts are reviewed once a month to ensure that deficiencies do not recur. |
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 an assessment of the client's progress in relationship to the stated goals of the prior treatment plan on the treatment plan update in seven of seven client records reviewed.
Findings:
Seven client records were reviewed on April 14, 2009. An assessment of the client's progress in relationship to the stated goals of the prior treatment plan was required in seven client records. The facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan in client records #1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
Clinical Director will incorporate in newly revised treatment plan a section requiring the stated progression or regression of the consumer in the treatment process as it pertains to established goals.
Training on the newly revised treatment plan was conducted on May 29, 2009 by a Behavioral Health Consultant. The Quality Assurance team will audit the chart once per month to ensure that this deficiency does not reoccur. |
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 case consultation notes in six of seven client records reviewed.
Findings:
Seven client records were reviewed on April 14, 2009. Case consultation notes were required every 90 days as per facility policy in seven client records. The facility failed to document case consultation notes as of the ending date of the inspection in client records #1, 3, 4, 5, 6 and 7.
Client #1 was admitted on 1/7/09. A case consultation was due on 4/7/09. Client #3 was admitted on 1/2/09. A case consultation was due on 4/2/09. Client #4 was admitted on 6/12/08. A case consultation was due on 9/12/08 and 12/12/08. Client #5 was admitted on 8/26/08. A case consultation was due on 11/26/08 and 2/26/09. Client #6 was admitted on 11/25/08. A case consultation was due on 2/25/09. Client #7 was admitted on 7/14/08. A case consultation was due on 10/14/08.
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Plan of Correction
Clinical Director will ensure that the existing Case Consultation process is implemented on a regular basis of every 90 days. Clinical Director will devise a system that will remind the primary counselor of when Case Consultations are due on each individual receiving treatment. The particpants of the Case Consultation will be the Clinical Director, Clinical Supervisor, and Primary Counselor. The Clinical Supervisor will ensure that the consultation is scheduled, followed by the Clinical Director ensuring that the session takes place and is documented and place in the consumer's chart.
Charts will be audited once a month by the Clinical Supervisor to ensure that all consultations are up-to-date and the deficiency doesn't recur. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary to include the reasons for treatment, services offered and/or the client's status or condition upon discharge in four of seven client records reviewed.
Findings:
Seven client records were reviewed on April 14, 2009. A discharge summary was required in four client records. The facility failed to document a discharge summary to include reasons for treatment in client records #4, 5, 6 and 7. The facility failed to document a discharge summary to include services offered in client records #4, 5 and 7. The facility failed to document a discharge summary to include client status in client record #6.
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Plan of Correction
Clinical Director will develop and implement newly devised Discharge Forms that will incorporate necessary information such as consumer discharge note, discharge summary and aftercare plan.
A designated Behavioral Health Consultant will hold training regarding the newly devised Discharge Forms on 6/19/09. Chart Audits will occur once a month by Quality Assurance Team. |
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 a review of client records, the facility failed to document follow-up information in four of seven client records.
Findings:
Seven client records were reviewed on April 14, 2009. Follow-up information was required in four client records. The facility failed to document follow-up information in client records #4, 5, 6 and 7.
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Plan of Correction
Clinical Director will develop a process by which one assigned designee is to complete consumer follow-up at various intervals according to established policy.
Clinical Director has appointed and will direct a Quality Assurance Team to review charts every 2nd Friday of each month and report findings to ensure reoccurnce of infractions doesn't occur. |