INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 3 and 4, 2009 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 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 April 4, 2009.
|
Plan of Correction
|
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
|
Observations
Based on a review of personnel records, the facility failed to document that the project director met the qualifications for the position.
Findings:
Personnel records were reviewed on March 3, 2009. The facility failed to document two years of experience for employee #1 in a human service agency which includes supervision of others and program planning.
|
Plan of Correction
The Executive Director of Rehab After Work will update his resume to include the two years of management experience, supervision of others, and program planning as required under the State Regs. This updated resume will be placed in the Executive Director's personel file at the Paoli location. |
704.8(a) LICENSURE Qualifications-Counselor Assistant
704.8. Qualifications for the position of counselor assistant.
(a) A person who does not meet the educational and experiential qualifications for the position of counselor may be employed as a counselor assistant if the requirements of at least one of the following paragraphs are met. However, a project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
|
Observations
Based on a review of client records and an interview with the facility director, the facility failed to document the qualifications for the position of counselor assistant in one of one personnel record.
Findings:
Client records were reviewed on March 4, 2009. An interview with the facility director was conducted on March 4, 2009. Client record #6 documented individual session progress notes for February 10 and 24, 2009 for employee #7 who was identified as an intern. Employee #7 was not identified on the staffing form. Upon request, the facility failed to provide documentation of education or experience for employee #7.
|
Plan of Correction
Effective immediately The Site Director of Paoli will meet with employee #7 and review State Guidelines regarding the use/supervision of Counselor Assistants. The Site Director will have employee #7 sign off that they understand the intent of these regulations & will comply with State guidelines. Staff training will take place on 4-22-09. The Site Director will monitor Employee #7 for the next 60 days to ensure that these guidelines are enforced.Correction will be completed on 4-30-09. |
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.
|
Observations
Based upon an interview with the facility director and a review of client records, the facility failed to document direct supervision for employee #7.
Findings:
Personnel records and the staffing form were reviewed on March 3, 2009. Employee #7, an intern, was not identified on the staffing form and no personnel record was documented. Client records were reviewed on March 4, 2009. A review of individual session progress notes for client #6 for February 10 and 24, 2009 documented that the session was provided by employee #7 who was identified as an intern. The progress notes were not co-signed by another counselor or a supervisor. The facility did not document any education or experience for employee #7 so would be required to provide documentation of direct supervision for this employee which the facility failed to do.
|
Plan of Correction
The Site Director of Paoli will meet with employee #7 and the counselor responsible for supervision to ensure that progress notes are co-signed, proof of experience & education are obtained, and that weekly supervision is documented. The Site Director will monitor compliance on a weekly basis (supervision log)until the standard has been met. Staff Training will take place on 4-29-09. Corrective action will be completed on 5-30-09. |
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 a review of personnel records, the facility failed to document HIV/Aids training in two of four personnel records reviewed.
Findings:
Personnel records were reviewed on March 3, 2009.
The facility failed to document HIV/Aids training for employee #5 and 6.
Employe #5 was hired as a counselor on xx/xx/xxxx.
Employee was hired as a___________ on xx/xx/xxxx.
|
Plan of Correction
The Site Director of Paoli will ensure that employee #5 & # 6 enroll in an state approved HIV training seminar. The Site Director will monitor compliance on a monthly basis until this standard has been met. Each employee will give proof of attendance to the Site Director, who will place this documentation in their personel files at the Paoli office.Staff training took place on 4-15-09. Corrective action will be completed on 7-15-09 |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on the physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
Findings:
The physical plant inspection was conducted on March 4, 2009 between 9:30 and 10:00 AM. The facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. The windows were uncovered in the adolescent therapist's office and in the office of employee #6.
|
Plan of Correction
The Site Director of Paoli with assistance from the Executive Director, will obtain window blinds for each counseling office affected. The blinds will be installed by contractor hired by Rehab After Work. The Site director of Paoli will meet with each counselor to discuss/document the need for blinds to be "closed" while clients are in session.Site director met with each counselor 0n Wednesday, 3-25-09. Window blinds were installed in each office on 4-1-09 |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on the physical plant inspection, the facility failed to ensure that hot water temperature did not exceed 120F.
Findings:
The physical plant inspection was conducted on March 4, 2009 between 9:30 and 10:00 AM. The hot water temperature in both bathrooms was 135 degrees F.
|
Plan of Correction
The Executive Director of Rehab After Work will hire an outside contractor to correct the water temperature problem at the Paoli office. The outside contractor will provide documentation that the water temperature was tested and that it does not exceed 120F. |
709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
|
Observations
Based on a review of client records and an interview with the facility director on March 4, 2009, the facility failed to document verification of training experience and professional licensure or registration for one of seven employees.
Findings:
During the review of client records on March 4, 2009, progress notes in client record #6 dated February 10 and February 24, 2009, were signed by employee #7. The facility failed to include employee #7 on the staffing form and failed to provide verification of training experience for employee #7.
|
Plan of Correction
The Executive Director of Rehab After Work will revise the Policy & Procedures section on the use of Volunteers/Interns to include a section on proof of intern training, education, and experience. This information will be kept in the personel file at the Paoli office. |
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 a review of client records and the review of the Business Associate Agreement with Calloway Labs, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in eight of fourteen client records reviewed. The facility also used consents to release information forms which contained "obtain from" language in twelve of fourteen client records reviewed.
Findings:
Fourteen client records were reviewed on March 4, 2009. The Business Associate Agreement with Calloway Labs was reviewed on March 4, 2009. The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to Calloway Labs in client records #2, 3, 7, 8, 9, 10, 13 and 14. The Business Associate Agreement with Calloway Labs only referenced HIPAA regulations and did not comply with 42 CFR Part 2 Subpart B Subsection 2.12(c) (4). The consent to release information forms also contained "obtain from" language in client records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
|
Plan of Correction
The Executive Director of Rehab After Work will work with Calloway Labs Associate to udate the Business Associate Agreement to include language pertaining to 42 CFR Part 2 Subpart B Subsection 2.12(c)(4). The new agreements will be distributed to all Rehab After Work Locations. Also, the consent to release information forms will be reprinted without the language "obtained from" on them. The Executive Director of Rehab After Work will monitor progress on both tasks until we are in full compliance with the standard. All Rehab After Work locations received new informed and voluntary consents on 4-10-09. All consents had "obtained from" language removed.Additionally, on 4010-09 a specific informed and voluntary consent for Calloway Labs was distributed to each RAW locatiion. Each client will be asked to sign a consent before using Calloway Labs.Effective immediately each client record will contain a consent for drug screen requests.A staff training regarding use of consent forms was conducted on 4-15-09 The site director will monitor compliance on a weekly basis until the standard has been met. Corrective action will be completed on 5-15-09. |
709.28(c)(2) 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:
(2) Specific information disclosed.
|
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 one of twelve client records.
Findings:
Fourteen client records were reviewed on March 4, 2009. An informed and voluntary consent for the disclosure of information was required in twelve client records. The facility failed to provide an informed and voluntary consent for information released to the insurance company in client record #14. The information released to the funding source included treatment notes, diagnostic test results and procedure reports.
|
Plan of Correction
The Site Director of Paoli will meet with the counselor of client record #14 and review through in-service training the state guidelines regarding release of information. The counselor of client record #14 will sign off that they recieved this training & understand the intent of the state regulations. The Site Director of Paoli will randomly audit charts on a monthly basis until the standard has been met. Staff training will occur on 4-22-09. Corrective action will be completed on 5-1-09. |
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 eleven of eleven client records.
Findings:
Fourteen client records were reviewed on March 4, 2009. Psychosocial evaluations were required in eleven client records. The facility did not document a psychosocial evaluation in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 13 and 14
The facility did not document a psychosocial evaluation to include the client ' s assets/strengths in client records # 4, 5, 9, and 13.
The facility did not document a psychosocial evaluation to include the client ' s support systems in client records # 1, 2, 3, 6, 8 and 14.
The facility did not document a psychosocial evaluation to include the client ' s coping mechanisms in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 13 and 14.
The facility did not document a psychosocial evaluation to include the client ' s negative factors in client records # 1, 2, 3, 4, 5, 9, 13 and 14.
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 # 5, 6, 7, 8, 9, 13 and 14.
|
Plan of Correction
The Site Director of Paoli will conduct and in-service training on all components of the psychosocial assessment for all staff at the Paoli office. The site director will be responsible for ensuring that the corrective actions are implemented. All Paoli staff will sign off that they attended this training & understand the intent of the state regulation. The Site Director of Paoli will randomly audit charts on a monthly basis to ensure that this standard has been fully met. The staff training will occur on 4-29-09. Corrective action will be completed by 5-29-09. |
709.92(a) 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:
|
Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan developed with the client in eleven of eleven client records.
Findings:
Fourteen client records were reviewed on March 4, 2009. An individual treatment and rehabilitation plan developed with the client was required in eleven client records.
The facility did not document treatment plans developed with the client in records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 13 and 14.
The treatment plans were not signed by the client, and there was no documentation, in the client ' s progress notes, of the client participating in the development of the treatment plan.
|
Plan of Correction
The Site Director of Paoli will conduct an in-service training for all Paoli staff regarding the process of having each client co-sign the Master Treatment Plan. All Staff at Paoli will sign off that they attended the training and understand the intent of the state standard. The Site Director of Paoli will perform monthly, random chart audits until the standard meets full compliance.Staff training occurred on 4-15-09. Corrective action completed by 6-1-09. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plans to include proposed types of supportive services in five of twelve client records.
Findings:
Fourteen client records were reviewed on March 4, 2009. Treatment plans with proposed types of supportive services were required in twelve client records. The facility did not document treatment plans with proposed types of supportive services in client records #s 2, 4, 8, 9 and 13.
|
Plan of Correction
The Site Director of Paoli will conduct a training educating counselors on external support services required for all clients on treatment plans as required by state regulations. Staff will sign off indicating that they attended and understand the training. Site Director will conduct monthly audits on a random basis to ensure that the standard is met.Staff training occurred on 4-15-09.Corrective action will be completed by 5-30-09. |
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.
|
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 nine of nine client records reviewed.
Findings:
Fourteen client records were reviewed on March 4, 2009. An assessment of the client's progress in relationship to the stated goals of the prior treatment plan was required in nine 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, 7, 13 and 14.
|
Plan of Correction
The Site Director of Paoli will conduct a training educating counselors on the components of the treatment plan update with emphasis of progress/lack of progress on prior treatment goals. Staff will sign off that they attended the training and understand the intent of the state regulation. Site Director will conduct monthly audit to ensure that that the standard is in full compliance.Staff training will occur on 4-22-09. Corrective action will be completed by 5-4-09. |
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.
|
Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in four of ten client records.
Findings:
Fourteen client records were reviewed on March 4, 2009. Counseling services provided according to the individual treatment and rehabilitation plan were required in ten client records. The facility failed to document, either in the record of services or progress notes, that counseling services provided according to the individual treatment and rehabilitation plan in client records #5, 6, 7 and 10.
Individual sessions were prescribed one time per week in client record #5. The facility documented individual sessions on 12/9, 12/16 and 12/23/08, 1/6, 1/7 and 2/25/09.
Individual sessions were prescribed for two times per month in client record #6. The facility documented one individual session in January, on 1/22/09.
Individual sessions were prescribed one time per week in client record #7. The facility documented individual sessions on 10/28/08, 1/7, 1/23, 1/30, 2/6, 2/13 and 2/27/09.
Group sessions were prescribed for three times per week in client record #10. The facility documented group sessions on 11/4. 11/7, 11/18, 11/21, 11/25, 12/1, 12/5, 12/9, 12/12 and 12/16/08.
|
Plan of Correction
The Site Director of Paoli will conduct an in-service training on use of the record of service & progress notes to accurately reflect the frequency/type of treatment services in accordance with the stated treatment plan. All Paoli staff will sign off that they attended the training & understand the intent of the regulation. The Site Director of Paoli will conduct monthly follow-up chart audits to ensure that this standard is in full compliance.Staff training occurred on 4-15-09. Corrective action will be completed by 6-13-09. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
|
Observations
Based on a review of client records, the facility failed to document that counseling was provided to a client on a regular and scheduled basis in nine of twelve client records.
Findings:
Fourteen client records were reviewed on March 4, 2009. Counseling provided to a client on a regular and scheduled basis was required in twelve client records. The facility failed to document at least one individual session every 60 days for the completion of the comprehensive treatment plan and treatment plan update in client records #1, 2, 3, 4, 5, 6, 7, 13 and 14.
|
Plan of Correction
The Site Director of Paoli will conduct an inservice training regarding the need to document at least one individual session every 60 days while a client is in treatment. These session should be used to discuss the Treatment Plan/Update. All paoli staff will sign off they attended the training and understand the regulation. The Site Director of Paoli will conduct monthly, random chart audits until the standard has been met. Staff training occurred on 4-15-09. Corrective action will be completed by 5-30-09. |
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
Based on a review of client records, the facility failed to document follow-up information in three of seven client records where required.
Findings:
Fourteen client records were reviewed on March 4, 2009. Follow-up information was required in seven client records. The facility failed to document follow-up information in client records #10, 12 and 13.
|
Plan of Correction
The Site Director of Paoli will meet with the counselor of client records #10, 12, and 13. These counselors will be required to attend an inservice training on the proper way to document follow-up information. The counsleors will sign off that they attended this training and understand how to document followup information. The Site Director of Paoli will perform random, monthly chart audits until the standard is in full compliance.Staff training occurred on 4-15-09. Corrective action will be completed by 4-30-09. |