INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9, 2016 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.
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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 a review of personnel records, the facility failed to ensure that the 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. The findings include:One clinical supervisor record was reviewed on February 9, 2016. Employee # 1, a clinical supervisor was hired for the position on March 30, 2015. The facility failed to ensure employee # 1 completed a core curriculum in clinical supervision. Employee # 1 has approximately 5 years clinical experience; however, no documentation of supervisory experience in the provision of clinical services. Thus, employee # 1 was required to complete the core curriculum in clinical supervision.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselor #1 will meet with the RAW clinical director on a monthly basis until the required training has been completed. HR department will sign Employee #1 up for the core curriculum in clinical supervision training by 3/30/16. The training will be completed and verification of completion will be put into Employee's personnel file. In order to ensure that this type of citation does not re-occur, the steps that will be taken will include 1.making sure that future clinical supervisors meet the qualifications for the position or 2.The potential clinical supervisor will be signed up for the core curriculum before being placed in that position if they have less than 2 years' experience. |
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 and a review of the Staffing Requirements Facility Summary Report form, the facility failed to ensure that staff persons 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. All other staff shall complete the training within the first 2 years of employment. The findings include:One personnel record requiring documentation of 6 hours HIV/AIDS training and at least 4 hours of TB/STD training were reviewed on February 9, 2016; in addition to a review of the Staffing Requirements Facility Summary Report form. The facility failed to ensure all staff persons received a minimum of 6 hours HIV/AIDS training and at least 4 hours of TB/STD training. Employee # 4, a counselor was hired May 1, 2014. HIV/AIDS training and TB/STD training was to be completed within the first year of employment or by May 1, 2015. The facility failed to ensure that employee # 4 completed the required training's. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The site director of Lansdale will meet with counselor #4 to ensure that he successfully completes a four hour Tuberculosis/STD training and a 6 hour HIV training. Counselor will schedule the training by 3/30/16. Counselor #4 will provide verification that he attended this training and the site director will put the certificates in his personnel file. New clinicians who are hired that don't already have these mandatory trainings will discuss progress with scheduling the trainings during supervision. After 6 months, if the trainings still haven't been completed, coaching will be done to help the clinician find and schedule the required trainings. |
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:
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Observations
Based on a review of client records, the project failed to document informed and voluntary consent to release forms that complied with Pa Code 255.5.The findings include:4 Pa. Code 255.5 states:Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.(1) Whether the client is or is not in treatment.(2) Client's prognosis.(3) The nature of the project.(4) A brief description of the client's progress.(5) A short statement as to whether the client has relapsed Ten client records were reviewed on February 9, 2016. The project failed to document informed and voluntary consent to release forms in eight out of ten client records reviewed, # 1, 3, 4, 5, 6, 7, 8 and 9. 1. The project has a "Managed Care/Insurance Company Authorization to Release Information Form" that all clients sign and agree to consent to release. The "Managed Care/Insurance Company Authorization to Release Information Form" is a project wide template form. The other box is checked off on this template form with the pretext "level of care evaluations, Authorizations, Status reports and Recommendations, Chart contents." The release or documentation of the release of the client's "level of care evaluations and chart contents" does not comply with the stipulations of 255.5.2. In addition, the project has a form titled "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company - The Light Program/Life Counseling Services/Rehab After Work," that was revised 10/15.The form documents, "My signature below indicates my permission for The Light Program/Life Counseling Services/Rehab After Work to bill my insurance for payment. I give my permission to disclose information such as my diagnosis, my medication and dates I will be attending, as well as other pertinent information in order for my insurance company to grant authorization of my attendance." The release or documentation of the release of the client's "medication and dates I will be attending as well as other pertinent information in order for my insurance company to grant authorization of my attendance" does not comply and exceeds the limitations imposed at 255.5.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Site Director will conduct a training on Confidentiality with staff members during weekly staff meeting on March 14, 2016. During this meeting, Site Director will review regulations and policies regarding client confidentiality, 4Pa. Code 255.5. Site Director will perform quarterly audits of 12 charts minimum in order to monitor compliance with confidentiality regulations. Site director will perform these audits to ensure that the appropriate measures and documentation of confidentiality is being utilized in all consent forms on Rehab After Work paperwork, specifically stating the purpose for the release at hand. The current managed care consent form will be edited to utilize proper terminology and stay within the 4Pa. Code 255.5 regulation of confidentiality. The "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company" form will also be edited to comply with the 4Pa. Code 255.5 regulation of confidentiality. The new consent form was sent out to all Rehab After Work clinicians on January 18th, 2016 and will be utilized from that date moving forward, replacing the previous managed care consent form. All current clients who had the old form in their charts signed the new consent form and the new forms were placed in the chart. |