INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab Management Inc. was found to be not 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of staff records conducted on March 6-7, 2017, the facility failed to ensure that a staff member received the required training hours.
Employee #3 was hired as a counselor on 4/15/09 but received only 20.5 hours of training during the training year from 1/1/16 thru 12/31/16.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
RAW Clinical Supervisor will meet with all RAW clinicians in order to review the training standards and expectations. All RAW Clinicians will be re-educated on the 25 hour/year training requirement during the Staff Meeting on 4/12/17. RAW Clinical Supervisor will check in with each clinician, at least once a month during supervision, to review current progress with training hours. Each check in regarding training hours will be documented in the supervision note. RAW Clinical Supervisor will review the submitted training hours every three months in order to remain aware of each clinician's progress with meeting the training hours requirement. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of staff records conducted on March 6-7, 2017, the facility failed to document that a staff member received an annual work performance evaluation for 2016.
Employee #3 was hired as a counselor on 4/15/09. An evaluation was found in the chart dated 9/21/15, however no current evaluation was documented.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
RAW Clinical Supervisor will review the dates of evaluation deadlines with the RAW clinicians during the Staff Meeting on 4/12/17. RAW Clinical Supervisor will keep an up to date calendar to reflect due dates of evaluations for each of the RAW clinicians. Evaluations will occur on or before the scheduled due dates and will be reviewed with the clinicians individually. Completed evaluations will be submitted to Human Resources in order to maintain accountability and assist in record keeping. FAW Clinical Supervisor will audit each clinician's file at least 15 days prior to the end of the year in order to ensure that all clinicians have been receiving their evaluations as scheduled.
RAW Clinical Supervisor will complete the evaluation for Clinician #3 by 4/30/17 and this eval will be submitted to Human Resources by 5/1/17. |
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
Seven client records were reviewed on March 28, 2017. The facility failed to obtain a valid consent to release information in client records #1 & 6.
Additionally, the project has a form titled "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company " which was found in client records #2, 3, 4, 5, 6 & 7.
This form authorizes the release of the client's medication, and dates of attendance as well as "other pertinent information in order for my insurance company to grant authorization of my attendance" which exceeds the limitations imposed at 4 PA Code 255.5.
Client #1 was admitted on 9/8/15 and was an active client at the time of the licensing inspection. Two consents to releases dated 9/6/15, one to a lab and one to a funding source, expired one year from the date of the client signature and had not been updated with valid releases at the time of the licensing inspection.
Client #2 was admitted on 9/8/16 and was an active client at the time of the licensing inspection. "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company " dated 9/23/16.
Client #3 was admitted on 10/24/16 and was an active client at the time of the licensing inspection. "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company " dated 10/24/16.
Client #4 was admitted on 9/19/16 and was discharged on 11/9/16. "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company " dated 9/20/16.
Client #5 was admitted on 7/18/16 and was discharged on 12/27/16. "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company " dated 7/18/16.
Client #6 was admitted on 9/27/16 and was discharged on 12/9/16. Two consents to releases dated 9/27/16 did not specify the name of a person or agency to whom the information was to be disclosed, and one of these consents did not specify the purpose of the disclosure. Additionally, there was a facsimile transmission to a lab dated 11/10/16, however there was no consent to release information to this lab. At the time of the inspection there was no consent to release information to the client's funding source. "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company " dated 9/27/16.
Client #7 was admitted on 10/6/16 and was discharged on 1/20/17. "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company " dated 10/6/16.
This is a repeat citation.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
RAW Clinical Supervisor will utilize the staff meeting on 4/12/17 to re-educate staff on the updated form of the Financial Responsibility Agreement & Authorization to Release Information and compliance with PA Code 255.5; RAW Clinical Supervisor will also re-educate RAW clinicians on PA Code 255.5 to ensure understanding of this standard. Program Coordinator emailed all RAW clinicians on 3/28/17 with the updated version of these forms. Paper copies of the forms will be supplied in the staff meeting on 4/12/17. RAW Clinicians will be instructed to discard of all older forms that are not in compliance with PA Code 255.5. Program Coordinator will conduct a site walk-through on 4/12/17 to check for the presence of the out of date form.
Clinicians who work with Client #3 and Client #4 will review the up to date form with these clients and have them sign these forms by the end of April. RAW Clinical Supervisor will check for compliance with this expectation on May 1st to ensure the updates have been made in these active charts.
The clinician who works with Client #1 will obtain updated releases of information by the end of April. This clinician will also obtain a release of information for the lab in which client's information is being released to. RAW Clinical Supervisor will check for compliance with this expectation via a chart audit on May 1, 2017.
RAW Clinical Supervisor will re-educate all clinicians on releases of information, including the requirement of obtaining these written releases as well as only placing fully completed releases of information into a client's chart.
RAW Clinical Supervisor will audit at least 10 active charts per quarter to ensure that compliance with the full completion of releases of information and use of the updated Financial Responsibility Agreement & Authorization form is occurring. |
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
Seven client records were reviewed on March 28, 2017. The facility failed to update the treatment plan every 60 days in client records, #1, 5, 6 & 7.
Client #1 was admitted on 9/8/15 and was an active client at the time of the licensing inspection. A treatment plan update was created on 9/12/16; a treatment plan update was due by 11/12/16 but was not documented until 1/30/17.
Client #5 was admitted on 7/18/16 and was discharged on 12/27/16. A comprehensive treatment plan was created on 7/21/16; a treatment plan update was due by 9/21/16 but was not documented at the time of the licensing inspection.
Client #6 was admitted on 9/27/16 and was discharged on 12/9/16. A comprehensive treatment plan was created on 10/4/16; a treatment plan update was due by 12/4/16 but was not documented at the time of the licensing inspection.
Client #7 was admitted on 10/6/16 and was discharged on 1/20/17. A comprehensive treatment plan was created on 10/27/16; a treatment plan update was due by 12/26/16 but was not documented until 12/28/16.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
RAW Clinical Supervisor will review the standards regarding treatment plans and treatment plan updates on 4/12/17 at the staff meeting. RAW Clinical Supervisor will review the requirement that treatment plan updates are required within 60 days of the previous plan. RAW Clinical Supervisor will audit at least 10 active charts per quarter in order to assess timely completion of the treatment plan updates.
RAW Clinical Supervisor will audit chart for Client #1 by 4/12/17 to ensure that the most recent treatment plan update has been completed. If this update needs to be completed, clinician for Client #1 will complete the update no later than 4/30/17. |
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
Seven client records were reviewed on March 28, 2017, the facility failed to provide treatment according to the client's individualized treatment plan in client records #5, 6 & 7.
Client #5 was admitted on 7/18/16 and was discharged on 12/27/16. The comprehensive treatment plan dated 7/21/16 indicated IOP group counseling, 4 times per week, however the record of service indicated group was provided on the following dates:
7/18, 7/20, 7/21, 7/25, 7/27, 8/1, 8/4, 8/11, 8/15, 8/17, 8/24, 8/25, 8/29, 9/8, 9/29, 10/20. There was no documentation of services provided to the client between 9/8 through 9/29, 9/29 through 10/20 and 10/20 through 12/19/16.
Client #6 was admitted on 9/27/16 and was discharged on 12/9/16. A treatment plan update dated 10/4/16 indicates indicated IOP group counseling, 4 times per week, however the record of service indicated group was provided on the following dates:
10/3, 10/5, 10/10, 10/12, 10/17, 10/19, 10/20, 10/24, 10/26, 11/2, 11/3, 11/7, 11/9, 11/10, 11/14, 11/17, 11/21, 12/1/16.
Client #7 was admitted on 10/6/16 and was discharged on 1/20/17. A treatment plan update dated 10/27/16 indicates indicated IOP group counseling, 4 times per week, however the record of service indicated group was provided on the following dates:
10/31, 11/7, 11/9, 11/10, 11/14, 11/16, 11/17, 11/21, 11/23, 11/25, 12/1, 12/5, 12/7, 12/14, 12/15, 12/19, 12/21, 12/22, 12/26, 12/28/16.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
RAW Clinical Supervisor will review the treatment plan form with the RAW clinicians on 4/12/17 at a staff meeting. RAW Clinical Supervisor will re-educate clinicians regarding the frequency prompt on the treatment plan form. RAW Clinical Supervisor will train clinicians on using client-centered approaches to assess the availability of the client to attend group sessions, then using the information obtained from the client to determine the expected frequency of participation.
RAW Clinical Supervisor will train clinicians on documenting a client's absence in treatment during the staff meeting on 4/12/17. RAW Clinical Supervisor will train clinicians on use of the Service Record, Phone Log, and Progress Note to document the presence of, or absence of, a client. RAW Clinical Supervisor will re-educate clinicians on attempts to make contact with a client who is absent from treatment for at least one day and documenting the attempt at contact.
RAW Clinical Supervisor will complete at least 10 chart audits per quarter in order to assess that the frequency of visits is aligned with the documentation in the chart. |