INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16-17, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
During a licensing inspection conducted on July 16-17, 2019, the facility failed to provide documentation of direct observation for the first three months and close supervision for the following nine months for employee # 7.
Employee # 7 was hired as a counselor assistant on February 25, 2019 and was still in this position as of the date of the onsite inspection. The employee is currently employed with a high school diploma and requires three months direct observation and nine months of close supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will ensure that a full-time clinical supervisor or counselor who meets the qualifications provides schedule weekly supervision session to counselor assistant during his/her three to nine months upon hire. The clinical supervisor and/or counselor will provide written documentation of the session and review the counselor assistant supervision notes during their supervision session with the project director to ensure compliance. In addition, the HR department will audit all staff chart quarterly to maintain compliance and if documentation is missing from the staff chart , HR will then send out notifications to the project director as well as the clinical supervisor and/or counselor. |
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
During a licensing inspection conducted on July 16-17, 2019 a review of employee trainings did not provide feedback forms as indicated in the projects Policy and Procedure Manuel in four of seven personnel records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The training coordinator will ensure that all employee training feedback forms is placed in each employee chart under the training section instead of placed in a binder. The staff training evaluation binder is in the training coordinator office and was not given for review at the time of the inspection.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
During a licensing inspection conducted on July 16-17, 2019, the facility failed to provide documentation of an individual training plan for employee # 1 and # 2.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The supervisors will ensure that all new employees training plan are completed within 7 days of hire. After supervisor review/complete the training plan with the new employee,then she/he will submit the entire completed orientation packet to the HR manager to be place in their chart including the individual training plan. In addition, the HR department will audit all employee chart quarterly and if documentation is missing , the HR Department will send out notifications to the project director, facility director and supervisors requesting the needed documentation. |
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
During a licensing inspection conducted on July 16-17, 2019, the facility failed to provide documentation to ensure that employee's # 4, 8, and 9 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee # 4 was hired on January 18, 2018 and promoted to current position on April 2, 2018. HIV/AIDS STD/TB training was due no later than January 18, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee # 8 was hired as a support staff on November 5, 2015 and was due to have the communicable disease trainings no later than November 5, 2017. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee # 9 was hired as a support staff on July 6, 2016 and was due to have the communicable disease trainings no later than July 6, 2018. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MWFHE 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. To ensure training completion compliance for DDAP regulatory training timeframe, the training coordinator will revise the standard employee training tracking checklist document in order to maintain accurate employee training records, needs and to make it easier to track training that employees miss. The training coordinator will also audit employees training records monthly instead of quarterly to keep up with those employees who does not attend schedule mandated training without supervisor approval. In addition, the HR department will also audit all employees chart quarterly and if documentation and/or training certificates are missing , then the HR manger will send out emails to the training coordinator, project director, facility director and supervisors' requesting these documents. |
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
During a licensing inspection conducted on July 16-17, 2019, the facility failed to provide documentation of an annual financial audit for the years of 2017 and 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure available of the 2017-2018 Financial Audit by 12/1/2019. Going forward the Facility Director will follow-up with the Project Director within 90 days before the agency fiscal year ends (December) to ensure the availability of the prior year Financial Audit Report submitted on the day of an inspection. The Facility Director will conduct training quarterly with management staff directors, managers, and supervisors on the proper preparation for all inspections in order to prevent recurrence of not having the availability of the financial audits report at the time of inspections. |
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.
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Observations
Based on a licensing inspection conducted on July 16-17, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 7.
Client # 7 was admitted on June 27, 2019 and was still an active client at the time of the inspection. An informed and voluntary consent form signed and dated by one client on June 27, 2019, to a lab, allowed for the disclosure of information for another named client ' s information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
6. To ensure client confidentiality is maintained and prevent client's information at risk ...The clinical supervisor and lead counselor will make sure all client confidential information is properly file within his/her own chart ... the clinical supervisor and lead counselor will conduct audits and chart reviews weekly to address any areas of concern immediately. These could include missing document, miss file documents, missing psychiatrist signature, and/or missing codes. The weekly audits and chart reviews process will help us and our client information from issues of having confidentiality breaches. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
During a licensing inspection conducted on July 16-17, 2019, the facility failed to provide a policy and procedure to include a reporting mechanism to ensure that reporting of an unusual incident to the Department is in compliance with State and Federal confidentiality laws.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the "Policy #709.34- Procedures adding more detail instructions for employees about the process for reporting an unusual incident when they occur in our facility. These instructions will include, what types of incidence are unusual, what should be done, who to report to, and how to report to the Department (DDAP). As well as, our facility plans on how to ensure this deficiency does not occur in the future. (Completed by October 2, 2019)
The revised "Policy #709.34-Procedures Instructions will be as followed:
1. The clinical supervisor will create an unusual incident log and checklist document for staff to complete in order to ensure the proper procedures are carried out. (completed by October 2, 2019)
2. The training coordinator will schedule a staff in-service training to review the revisions and new documents linked to our "Policy #709.34 -Procedures (no later than October 2, 2019). In-service training agenda will include (not limited to); reviewing entire "Policy #709.34, eight (8) unusual incident description, and reporting processes. (Intent of In-Service Training: To increase staff knowledge/skills in responding and reporting mechanism of unusual incidence when they occur in our facility)
3. All unusual incident will be reported to the clinical supervisor and/or lead counselor when they occur.
4. The clinical supervisor will then instruct office manager/designee staff to follow the written procedures instructions (in binder) for reporting located in at the front desk.
5. The office manager/designee staff will take the appropriate actions (calling police, fire or ambulance) needed to ensure health and welfare of individual involved and any at-risk individuals.
6. The office manager/designee staff will then submit final completed report (same day) to the clinical supervisor and/or lead counselor for their signature.
7. Then the clinical supervisor and/or lead counselor will submit a copy of the weekly unusual incident log sheet on Friday to the compliance manager.
8. The compliance manager will add unusual incident report to the weekly management agenda for October 2, 2019.
9. In the weekly management on October 2, 2019 the clinical supervisor will report on any issues and/or concerns of prior/current unusual incidence-and confirm they was fax to the Department (DDAP) in the timeframe. This facility plan will ensure this deficiency does not occur again.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a licensing inspection conducted on July 16-17, 2019, the facility failed to provide documentation of written unusual incident reports with the Department within 3 business days following an unusual incident involving events at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the "Policy #709.34- Procedures adding more detail instructions for employees about the process for reporting an unusual incident when they occur in our facility. These instructions will include, what types of incidence are unusual, what should be done, who to report to, and how to report to the Department (DDAP). As well as, our facility plans on how to ensure this deficiency does not occur in the future. (Completed by October 2, 2019)
The revised "Policy #709.34-Procedures Instructions will be as followed:
1. The clinical supervisor will create an unusual incident log and checklist document for staff to complete in order to ensure the proper procedures are carried out. (no later than September 13, 2019)
2. The training coordinator will schedule a staff in-service training to review the revisions and new documents linked to our "Policy #709.34 -Procedures (no later than September 26, 2019). In-service training agenda will include (not limited to); reviewing entire "Policy #709.34, eight (8) unusual incident description, and reporting processes. (Intent of In-Service Training: To increase staff knowledge/skills in responding and reporting mechanism of unusual incidence when they occur in our facility)
3. All unusual incident will be reported to the clinical supervisor and/or lead counselor when they occur.
4. The clinical supervisor will then instruct office manager/designee staff to follow the written procedures instructions (in binder) for reporting located in at the front desk.
5. The office manager/designee staff will take the appropriate actions (calling police, fire or ambulance) needed to ensure health and welfare of individual involved and any at-risk individuals.
6. The office manager/designee staff will then submit final completed report (same day) to the clinical supervisor and/or lead counselor for their signature.
7. Once the unusual incidence report is reviewed for proper completion and signed by the clinical supervisor and/or lead counselor then the office manager/designee staff will be responsible to fax the report to the Department (DDAP) within the 3-day timeframe. (all fax confirmation will be held in Binder)
8. Then the clinical supervisor and/or lead counselor will submit a copy of the weekly unusual incident log sheet on Friday to the compliance manager.
9. The compliance manager will add unusual incident report to the weekly management agenda for October 2, 2019.
10. In the weekly management on October 2, 2019 the clinical supervisor will report on any issues and/or concerns of prior/current unusual incidence-and confirm they was fax to the Department (DDAP) in the 3-day timeframe. This facility plan will ensure this deficiency does not occur again.
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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
During a licensing inspection conducted on July 16-17, 2019, the facility failed to provide documentation of treatment and rehabilitation updates at least every 60 days in three client records reviewed.
Client # 2 was admitted on April 2, 2019 and was still an active client at the time of the inspection. A preliminary treatment plan was developed on April 9, 2019. A comprehensive treatment and rehabilitation plan was to be developed no later than May 2, 2019 as determined by Project Policy and Procedure Manuel. There was no documentation in the client record.
Client # 4 was admitted on January 17, 2018 and discharged October 31, 2018. A treatment and rehabilitation plan update was completed May 30, 2018 and the next update was due no later than July 30, 2018. The next documented update occurred on September 4, 2018.
Client # 6 was admitted on February 7, 2018 and discharged on August 29, 2018. A treatment and rehabilitation plan update was completed May 2, 2018 and the next update was due no later than July 2, 2018. The next documented update occurred on August 2, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Lead counselor will develop a formalized" Weekly Client Chart Audit Sheet", by 9/30/2019 which will be made available at all future Inspections. Going forward, the lead counselor will have weekly supervision with counselors to review their charts. During this time, the lead counselor will then be utilizing the new audit sheet to help her identify any missing documentation. The client chart auditing weekly process will ensure that clinical documentation is completed within the appropriate timeframe to meet compliance requirement. In addition, the lead counselor will also provide weekly in-service training to all D & A counselors' that will help them gain more effective clinical skills. |
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
During a licensing inspection conducted on July 16-17, 2019, the facility failed to provide documentation assuring counseling services are provided according to the treatment and rehabilitation plan in two of seven records reviewed.
Client # 3 was admitted on March 14, 2019 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on April 11, 2019 indicating one individual session a week and three group sessions a week. The chart's record of service and progress notes indicated that the client had not received individual sessions the weeks of: April 21-27, May 5-11, May 26-June 1, June 2-8, 23-29 or 3 Group sessions the weeks of: March 17-29, March 31-April 6, April 7-27, May 5-11, May 26- June 1-29, June 30-July 13, 2019.
Client # 6 was admitted on February 7, 2018 and discharged on August 29, 2018. A comprehensive treatment and rehabilitation plan was developed with the client on March 2, 2018 and last updated August 2, 2018 indicating one individual session a week and three group sessions a week. The chart's record of service and progress notes indicated that the client had not received individual sessions the month of June 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the deficiency the lead counselor will assure counselors provides documentation including no-show notes for counseling services received or not according to client treatment and rehabilitation plan.
Every Monday the lead counselor will review with counselor their past week schedule and record of service sheet to verify clients who received counseling services and those who missed their counseling appointment in the past week.
Next, the lead counselor will meet with counselors for weekly supervision to review their clients chart's progress notes, treatment plans, case management , and discharge review in order to ensure counselors accountability that all required documentation is completed for each counseling services including no-show progress notes if a client missed their counseling appointment .
Then, the office manager and/or designee will review the appointment logbook and create a list of clients' who had missed the counseling appointment in the past week and email the list to the lead counselor. The lead counselor will then send an email to all counselors instructing them to complete a no-show note for their clients on the list stating the reason the client is not keeping his/her appointment.
Then, the office manager and/or designee will make every effort to reschedule the client appointment as soon as possible this includes making follow-up appointments before clients leave the facility, and/or utilize the phone, text and email reminders. This will ensure that we support/help the clients keep appointments and work on improving the no-show rate.
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