INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on June 18-19, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Rhd Lower Merion Counseling Services 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document a Department approved core curriculum in supervision on one of one records reviewed.
The findings include:
On June 18, 2012, one personnel record identified as a clinical supervisor was reviewed for documentation of a core curriculum in clinical supervision. Personnel # 3 had no prior experience as a clinical supervisor and therefore required the Department approved core curriculum in supervision. Personnel # 3 was promoted to clinical supervisor on 11/22/11, but personnel # 3 ' s record did not contain documentation of a core curriculum in clinical supervision.
The findings were confirmed by the facility director on June 18, 2012.
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Plan of Correction
Personnel #3 is the current Assistant Director/Clinical Supervisor for LMCS. She was hired by LMCS as a therapist in April 2008. She was promoted to RST Coordinator/Supervisor in May 2010 and then to Assistant Director/Clinical Supervisor for LMCS in November 2011. Her duties as RST Coordinator/Supervisor required that she provided clinical oversight to the entire Recovery Support Team and Team Leaders. The resume in her personnel file at the time of the review was the original which she presented in 2008. Her resume has been updated to show relevant supervisory experienced and placed in her file.
She will attend the next scheduled Clinical Supervision course offered by BDAP. The date and time of the training will determined once BDAP has posted this information on its training site.
Going forward, the Program Director will ensure that this deficiency does not occur again by requiring all prospective Clinical Supervisors to attend this training prior to promotion.
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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 provide a minimum of 6 hours of training in HIV/AIDS and/or 4 hours of training in TB/STD in four out of five records reviewed.
The findings include:
On June 18, 2012, five personnel records were reviewed for 6 hours of training in HIV/AIDS and 4 hours of training in TB/STD, specifically records # 3, 11, 12, 13 and 14. The facility did not document 6 hours of training in HIV/AIDS and/or 4 hours of training in TB/STD, in records # 11, 12, 13 and 14.
Personnel # 11 was hired on 5/2/11. Personnel # 11 was required to receive 4 hours of training in TB/STD by 5/2/12. Personnel # 11 ' s record did not contain verification of this training at the time of review on 6/18/12.
Personnel # 12 was hired on 11/20/07. Personnel # 12 was required to receive 4 hours of training in TB/STD by 11/20/09. Personnel # 12 ' s record did not contain verification of this training at the time of review on 6/18/12.
Personnel # 13 was hired on 10/29/08. Personnel # 13 was required to receive 6 hours of training in HIV/AIDS and 4 hours of training in TB/STD by 10/29/10. Personnel # 13 ' s record did not contain verification of these trainings at the time of review on 6/18/12.
Personnel # 14 was hired on 6/19/08. Personnel # 14 was required to receive 6 hours of training in HIV/AIDS and 4 hours of training in TB/STD by 6/19/10. Personnel # 14 ' s record did not contain verification of these trainings at the time of review on 6/18/12.
An interview with the facility director on June 18, 2012 confirmed the findings.
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Plan of Correction
In May 2012, RHD applied to BDAP to become a host facility with approved trainers for the mandatory 6 hours of training in HIV/AIDS and 4 hours of training in TB/STD. In anticipation of this approval, RHD has scheduled trainings for TB/STD on August 22, 9:00am ? 1:00pm and HIV/AIDS on September 28, 9:30am ? 4:30pm. In the event that BDAP does not approve RHD to host these training, Personnel #11, 12, 13 and 14 will immediately register to attend these trainings at another BDAP approved training as soon as space permits.
Going forward, the Program Director will immediately remove any staff member from the schedule who has not completed these training within the allotted amount of time. The staff member will not be allowed to resume work until the trainings have been completed.
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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 fire drill log, the facility failed to maintain written fire drill records to include the exit route used and whether the fire alarm or smoke detector was operative.
The findings include:
On June 19, 2012, the facility ' s fire drill log was reviewed. The monthly fire drill reports for year 2012 were all incomplete. The fire drill reports did not state the exit routes used during fire drills, and they did not state whether the fire alarm or smoke detector was operative.
An interview with the facility director on June 19, 2012 confirmed the findings.
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Plan of Correction
The Fire Drill Form was updated on June 18, 2012 to include a check-off box that indicates the exit route that was taken during the drill, "Front Exit or Back Exit". A section was added to the form that requires the person completing the drill to indicate whether the fire alarm or smoke detector is operative.
The Program Director is responsible for ensuring the corrective action is implemented and will monitor to ensure the forms are completed correctly. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility ' s fire drill log, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
On June 19, 2012, the facility ' s fire drill log was reviewed. The monthly fire drill reports for year 2012 did not indicate the exit routes used during fire drills. It was not possible to determine if the facility had prepared alternate exit routes during fire drills.
The findings were confirmed by the facility director on June 19, 2012.
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Plan of Correction
The Fire Drill Form was updated on June 18, 2012 to include a check-off box that indicates the exit route that was taken during the drill, "Front Exit or Back Exit". The Fire Drill Policy was updated on June 18, 2012 to instruct staff members who complete fire drills to alternate exit routes during drills and indicate the route used by checking "Front Exit or Back Exit" on the form.
The Program Director is responsible for ensuring the corrective action is implemented and will monitor to ensure the forms are completed correctly. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility ' s fire drill log, the facility failed to set off a fire alarm or smoke detector during each fire drill.
Findings:
On June 19, 2012, the facility ' s fire drill log was reviewed. The monthly fire drill reports for year 2012 did state whether a fire alarm or smoke detector was activated during fire drills.
An interview with the facility director on June 19, 2012 confirmed the findings.
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Plan of Correction
The Fire Drill Form was updated on June 18, 2012 to include a check-off box that indicates how people are alerted that a fire drill is taking place, "HORN/WHISTLE, SMOKE DETECTOR, PULLED ALARM". The Fire Drill Policy was updated on June 18, 2012 to instruct staff members who complete fire drills to document on the fire drill form how people in the building are alerted to the drill.
The Program Director is responsible for ensuring the corrective action is implemented and will monitor to ensure the forms are completed correctly. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to adopt consistent policies for developing treatment and rehabilitation plans. The policy manual contained two inconsistent policies for treatment plans.
The findings include:
The policy and procedure manual was reviewed on June 19, 2012. The facility ' s policy for written procedures for the management of treatment contained two different procedures for documenting treatment plans.
The first policy stated:
" Upon completion of the assessment, the client and intake clinician will develop and initial treatment plan that will be approved and signed by the clinic psychiatrist within 15 days of admission to the program.
The second policy titled, " Individual treatment and Rehabilitation Plans " states:
" A preliminary treatment plan is completed at the time of intake. A comprehensive treatment plan is done at the first, second, or third, individual session with the primary therapist.
An interview with the facility director on June 19, 2012 confirmed the findings. The facility director stated they do not use preliminary treatment plans.
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Plan of Correction
The policies for written procedures for the management of treatment/rehabilitation plans have been updated to contain consistent information with regard to treatment planning. All policies now read, " Upon completion of the assessment, the client and intake clinician will develop an initial treatment plan that will be approved and signed by the clinic Director within 15 days of admission to the program. A comprehensive treatment plan will be done at the first, second, or third, individual session with the primary therapist and then every 60 days thereafter. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a physical plant inspection, the facility failed to secure all client records within locked storage containers.
The findings include:
An inspection of the facility ' s physical plant was conducted on June 19, 2012 between approximately 2:30 PM and 3:00 PM. Discharged client records were stored unlocked in stacked in boxes along the wall of the staff break room.
An interview with the facility director on June 19, 2012 confirmed the findings.
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Plan of Correction
LMCS will purchase three locking, Lateral File Cabinets that measure 52-1/2" H x 36 "W x 18-5/8" D to store the discharged client records. All the records will be placed in these locked cabinets on or before August 1, 2012.
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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 the review of client records, the facility failed to document a psychosocial evaluation to include a composite picture of the individual in relationship to the collected historical information in five of six records reviewed.
The findings include:
On June 19, 2012, six client records requiring psychosocial evaluations were reviewed, specifically records # 1, 2, 3, 4, 6 and 7. The facility did not document a psychosocial evaluation to include a composite picture of the individual in relation to the collected historical information in records # 1, 2, 3, 4 and 7.
Client # 1 was admitted on 3/15/12. The psychosocial evaluation in client # 1 ' s record, dated 3/15/12, did not include the client ' s assets and strengths, support systems, and conclusions regarding the client ' s appearance and behavior during the intake process.
Client # 2 was admitted on 5/4/12. The psychosocial evaluation in client # 2 ' s record, dated 5/4/12, did not include the client ' s assets and strengths, support systems, and conclusions regarding the client ' s appearance and behavior during the intake process.
Client # 3 was admitted on 2/2/12. The psychosocial evaluation in client # 3 ' s record, dated 2/2/12, did not include the client ' s support systems, coping mechanisms, and conclusions regarding the client ' s appearance and behavior during the intake process.
Client # 4 was admitted on 4/3/12. The psychosocial evaluation in client # 4 ' s record, dated 4/3/12, did not include the client ' s assets and strengths, coping mechanisms, negative factors, and conclusions regarding the client ' s appearance and behavior during the intake process.
Client # 7 was admitted on 11/1/11. The psychosocial evaluation in client # 7 ' s record, dated 11/10/11, did not include the client ' s assets and strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client ' s appearance and behavior during the intake process.
An interview with the facility director on June 19, 2012 confirmed the findings.
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Plan of Correction
The psychosocial evaluation was updated on 03/21/12 to include a full mental status section which addresses the appearance and behaviors of clients during the intake process. There are also sections that have been added to specifically address client strengths, assets, supports, coping skills/factors supporting treatment and negative factors/factors inhibiting treatment. During the review of the charts indicated, it was noted that some or all of this information was left out or failed to be completed by the therapist conducting the psychosocial evaluation. This is a training issue, which was addressed with all staff members at our Staff Meeting on June 26, 2012. It will continue to be addressed during every individual supervision session conducted in July and August and as needed with particular therapists following the review of the completed psychosocial evaluation by the Clinic Director.
- As of August 1, 2012 all staff will be proficient in completing a full summary of each client to include the historical information collected during the evaluation.
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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 the review of client records, the facility failed to assure that counseling services are provided according to the individual treatment plan in five of six out records reviewed.
The findings include:
On June 19, 2012, six client records were reviewed for counseling services being provided according to treatment plan, specifically in records # 1, 2, 3, 4, 6 and 7. The facility did not document counseling services according to the treatment plans in client records # 1, 3, 4, 6 and 7.
Client # 1 was admitted on 3/15/12. The treatment plan, in client # 1 ' s record dated 4/23/12 and the following treatment plan updates, state " individual counseling once per week " . Client # 1 ' s record did not contain documentation of individual counseling at least once per week. Individual counseling had only been documented on the following days:
3/15/12, 4/23/12, 5/17/12, 6/11/12 and 6/18/12.
Client # 3 was admitted on 2/2/12. The treatment plan, in client # 3 ' s record dated 2/15/12 and the following treatment plan updates, state " individual counseling once per week " . Client # 3 ' s record did not contain documentation of individual counseling at least once per week. Individual counseling had only been documented on the following days:
2/15/12, 2/22/12, 2/29/12, 3/7/12, 3/14/12, 3/28/12, 4/1/12, 4/24/12, 5/23/12, 6/6/12 and 6/13/12.
Client # 4 was admitted on 4/3/12. The treatment plan, in client # 4 ' s record dated 4/3/12, states " individual counseling once per week " . Client # 4 ' s record did not contain documentation of individual counseling at least once per week. Individual counseling had only been documented on the following days:
4/3/12 and 6/14/12.
Client # 6 was admitted on 11/15/11 and discharged on 3/13/12. The treatment plan, in client # 6 ' s record dated 11/30/12, states " individual counseling once per week " . Client # 6 ' s record did not contain documentation of individual counseling at least once per week. Individual counseling had only been documented on the following days:
11/30/12, 12/7/12 and 1/6/12.
Client # 7 was admitted on 11/1/11 and discharged on 5/4/12. The treatment plan, in client # 7 ' s record dated 11/10/11, states " individual counseling once per week " . Client # 7 ' s record did not contain documentation of individual counseling at least once per week. Individual counseling had only been documented on the following days:
11/10/11, 12/13/11 and 5/4/12.
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Plan of Correction
LMCS recently began using Service Rendered Sheets (SRS) for each client service that must be signed by the therapist and client prior to the beginning of a session. The therapists have been instructed to complete a progress note for each SRS, even if the client does not attend the appointment, so that a complete record of client progress is noted weekly according to the treatment plan. During the review of the charts indicated, it was noted that this information failed to be completed by the therapists if a client did not attend a weekly appointment. This is a training issue, which was addressed with all staff members at our Staff Meeting on June 26, 2012. It will continue to be addressed during every individual supervision session conducted in July and August and as needed with particular therapists following random chart reviews and Case Consultations.
- As of August 1, 2012 all staff will be completing progress notes weekly, even if the client does not attend the session, as per the treatment plan to show clients progress in treatment.
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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 the review of client records, the facility failed to document a case consultation at least quarterly in four out of seven records reviewed.
The findings include:
On June 19, 2012, seven client records requiring case consultations were reviewed, specifically records # 1, 2, 3, 4, 5, 6 and 7. The facility did not document a case consultation at least quarterly in client records # 3, 5, 6 ad 7.
Client # 3 was admitted on 2/2/12, but the case consultation in client # 3 ' s record was dated 6/6/12.
Client # 5 was admitted on 11/11/11 and discharged on 4/19/12. Client # 5 ' s record did not contain a case consultation at the time of review on 6/19/12.
Client # 6 was admitted on 11/15/11 and discharged on 3/13/12. Client # 6 ' s record did not contain a case consultation at the time of review on 6/19/12.
Client # 7 was admitted on 11/1/11 and discharged on 5/4/12. Client # 7 ' s record did not contain a case consultation at the time of review on 6/19/12.
An interview with the facility director on June 19, 2012 confirmed the findings.
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Plan of Correction
During the Staff Meeting held on June 26, 2012 is was addressed with all staff members that all charts must be closed if there is no activity for 60 days or more and Case Consultations are required on all open charts at least quarterly. LMCS has implemented a system by which all therapists must indicate when case consultations are require for each client by entering the clients name into the Supervisor's Log for review of the chart. Thiese requirements and procedures will be reiterated during individual supervision sessions and going forward following random chart reviews. Random chart reviews will be completed by the Director and/or Quality Control Specialist at least one time per month. |