INITIAL COMMENTS
|
This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 13-14, 2009 licensure renewal inspection. The follow-up inspection was conducted on December 4, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 January 9, 2010.
|
Plan of Correction
|
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.
|
Observations
Based on an interview with the clinical director, the facility failed to document
a minimum of 6 hours of HIV/AIDS and/or 4 hours of TB/STD training in three of three records.
The findings include:
An interview with the clinical director was conducted on December 4, 2009. Three personnel records that were reviewed during the licensing inspection on April 13-14, 2008 did not document at least 6 hours of HIV/AIDS and/or 4 hours of TB/STD training. The clinical director confirmed that these three personnel records still did not have documentation of HIV/AIDS and/or TB/STD training
Personnel #2 was hired in July 2007, but 4 hours of TB/STD training was not documented at the time of review on December 4, 2009
Personnel #5 was hired in March 2008, but 4 hours of TB/STD training was not documented at the time of review on December 4, 2009
Personnel #7 was hired in August 2004, but 6 hours of HIV/AIDS training was not documented at the time of review on December 4, 2009
|
Plan of Correction
The Clinical Supervisor will review all staff records to ensure that clinical staff have the reqiured 6 six hours in TB/STD, HIV/AIDS training within one year of hire date for counselors and two years for non- counselors. Clinical Supervisor will also review staff records on a quarterly basis to ensure that trainings are completed. |
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.
|
Observations
Based on an interview with the clinical director, 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.
The findings include:
An interview with the clinical director was conducted on December 4, 2009. The training records that were reviewed during the licensing inspection on April 13-14, 2008, did not document at least one person trained in CPR and first aid between the hours of 9:00 AM and 8:00 PM. The clinical director confirmed that the facility still did not have documentation of at least one person trained in CPR and first aid during the hours of 9:00 AM and 8:00 PM.
|
Plan of Correction
The Clinical Supervisor will review all staff records to ensure that the appropriate number of staff are on site during operation hours with CPR and First Aid training. Also the Clinical Supervisor will continue to review staff records on a quartly basis to ensure that their is at least one staff person with CPR and First Aid training on site during operation hours. |
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.
|
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.
The findings include:
The letters of agreement were reviewed and an interview with the clinical director was conducted on December 4, 2009. A written agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage was required. The facility did not document a written agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
The clinical director confirmed that a written agreement for 24-hour emergency medical coverage was not documented.
|
Plan of Correction
Executive Director is in continuing discussions to renew agreement with Fairmount Behavioral Health to provide 24hour emergency medical coverage. Also the Executive Director will meet with a licensed physician to also receive a written agreement to ensure 24-hour emergency psychiatric and medical coverage. The Executive Director will review all written agreement on a quartly basisi to ensure that MWFHE, Inc has the reqired written agreement that is require by the Division of Drug and Alcohol license. |
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:
|
Observations
Based on the review of client records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information contained in the client record in seven of seven client records.
The findings include:
Seven client records were reviewed on December 4, 2009. Informed and voluntary consent was required in seven client records. The facility did not document a Qualified Service Organization Agreement or a written consent for the disclosure of client information to a laboratory in client records #1, 2, 3, 4, 5, 6 and 7.
Client records 1, 2, 3, 4, 5, 6 and 7 included correspondence with a laboratory, but informed and voluntary consent from the client was not documented.
|
Plan of Correction
The Clinical Director has developed a form that allows clients to give inform and voluntary consent to laboratory for the purpose of urine sampling. Clinical Supervisor will conduct bi-weekly chart audits to ensure that informed and voluntary consents forms are being used and that client's are signing forms. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in five of six client records.
The findings include:
Seven client records were reviewed on December 4, 2009. Of those seven records psychosocial evaluations were required in six records. The facility did not document a psychosocial evaluation in client records # 2, 3, 5, 6 and 7.
The facility did not document a psychosocial evaluation to include the client ' s negative factors that might affect treatment in records # 2, 3 and 6.
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 records # 2, 3 and 6.
The facility did not document a psychosocial evaluation to include the client ' s preferred coping mechanisms in client records # 2, 3 and 6.
Client record # 5 admission date was 8/2/09, discharge date was 11/17/09, but a psychosocial evaluation was not documented at the time of review on 12/4/09.
Client record # 7 admission date was 8/5/09, discharge date was 11/5/09, but a psychosocial evaluation was not documented at the time of review on 12/4/09.
|
Plan of Correction
Clinical Director directly oversees all Intake/Assessments to ensure that psychosocials are completed on each patient.
Clinical Director has increased 1:1 clinical supervision with Intake Specialist to ensure that all components of the document are captured during the session.
Clinical Director conducts ongoing training for the Intake Specialist specifically in the areas of : Developing a strength-based document; Denoting the patient strengths and limitations; Addressing factors that impede/affect treatment;Coping Strategies of the Patient.
All Inatke materials to include the biopsychosocial are inspected by the clinical director for completeness. |
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.
|
Observations
At time of the follow-up review on 12/4/09, 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 records reviewed were not yet due to have follow-up information documented. Facility must resubmit original plan of correction.
|
Plan of Correction
Clinical Supervisor will review client's records bi-monthly to ensure that the follow-ups process have been peformed on clients who have been discharge from MWFHE's program. This process will began 30days after discharge. |