INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 21, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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.
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Plan of Correction
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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.
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Observations
Based on a review of the facility's hours of operation, the facility ' s staffing schedules and CPR certification & First Aid training cards, the facility failed to ensure that a sufficient number of staff persons trained in CPR and First Aid were onsite during the facility ' s hours of operation.
The findings include:
The facility's hours of operation are Monday through Friday, 9:00 AM to 8:00 PM.
The facility ' s staffing schedules and employee CPR certification & First Aid training cards were reviewed on May 21, 2014. The facility failed to provide documentation of CPR certification and First Aid training for employee # 11. The facility failed to ensure that at least one person trained in CPR and First Aid was onsite during the following days and times as employee # 11 was the only staff person working:
- No coverage on Monday's from 6 pm to 8 pm
- No coverage on Thursday's from 7 pm to 8 pm
An interview with the facility director on May 21, 2014 confirmed the findings.
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Plan of Correction
Staff working evening shifts who have not received CPR/FA training are scheduled to do so July 11, 2014. In the interim, additional staff who have completed the training have been scheduled to ensure there is coverage for every shift.
The CQI worker will keep a chart by shift of all workers with CPR-First Aid Training with expiration dates and organize it by shift. This will be updated monthly or when someone's shift changes who has the training.
The facility is not open past 5:00 on Fridays. This time period does not need to be covered. Our hours of operation are M-Th 9-8 and Friday 9-5. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that all heaters were permanently mounted or installed.
The findings include:
The physical plant inspection took place on May 21, 2014 at 3:50 pm. A heater that was not permanently mounted or installed was found in room # 12.
An interview with the facility director on May 21, 2014 confirmed the findings.
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Plan of Correction
Upon closer inspection, the item in question was not a heater, but was a fan. Management will ensure that no space heaters will be used in the building.
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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.
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Observations
Based on a review of the facility's letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
The letters of agreement were reviewed on May 21, 2014. The only letter of agreement regarding 24-hour emergency medical coverage was signed with a local hospital on October 21, 2011 for another RHD facility which is no longer operating as a drug and alcohol facility. The agreement stipulated that it was in effect for two years and therefore expired on October 21, 2013. There was no other documentation of a 24-hour emergency medical coverage agreement.
An interview with the facility director on May 21, 2014 confirmed the findings.
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Plan of Correction
After the state inspection, we received the signed agreement with Main Line Health Systems. The agreement is now in effect for emergency medical service referrals.
This referral renews every 2 years until one of the parties wishes it to stop or change the agreement. This assures that we are in compliance. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record, to include quarterly case consultations, aftercare plans and/or discharge summaries, in seven of ten client records reviewed.
The findings include:
Ten client records were reviewed on May 21, 2014. The facility failed to document a complete client record in client records # 1, 4, 5, 6, 7, 9 and 10.
Client # 1 was admitted on January 9, 2014. The facility failed to document a quarterly case consultation as of the date of the licensing inspection.
Client # 4 was admitted on October 7, 2013. The facility failed to document a quarterly case consultation during the fourth quarter of 2013 and the first quarter of 2014.
Client # 5 was admitted on September 6, 2013. The facility failed to document a quarterly case consultation during the fourth quarter of 2013 and the first quarter of 2014.
Client # 6 was admitted on August 22, 2013 and successfully discharged on December 5, 2013. The facility failed to document an aftercare plan for client # 6. The facility also failed to include the client's reason for treatment and the client's status at the time of their discharge on the discharge summary documented on December 5, 2013.
Client # 7 was admitted on October 2, 2013 and successfully discharged on February 12, 2014. The facility failed to document an aftercare plan for client # 7. The facility also failed to include the client's reason for treatment and the client's status at the time of their discharge on the discharge summary documented on February 12, 2014.
Client # 9 was admitted on August 14, 2013 and successfully discharged on February 20, 2014. The facility failed to document an aftercare plan for client # 9. The facility also failed to include the client's reason for treatment and the client's status at the time of their discharge on the discharge summary documented on February 20, 2014.
Client #10 was admitted on November 25, 2013 and successfully discharged on April 30, 2014. The facility failed to document an aftercare plan for client # 10. The facility also failed to include the client's reason for treatment and the client's status at the time of their discharge on the discharge summary documented on February 12, 2014.
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Plan of Correction
Therapists will hold monthly peer supervision to discuss cases (case Consultation) involving our D&A clients. A tracking sheet will be developed and maintained to track timeframes for aftercare, discharge information, and case consultations.
For those who are Fee for Service and not attending the meeting: The same tracking device will be used to connect therapists with a supervisor or fellow clinician to conduct consultations. This process will be overseen by the Assistant Director of LMCS
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