INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 12, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab Management Inc. Rehab After Work 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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704.6(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 staff records conducted on March 6-7, 2017, the facility failed to ensure that a clinical supervisor completed the core curriculum.
Employee #2 was hired as a clinical supervisor on 5/2/16 with less than 2 years of supervisory experience.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will attend a Core Curriculum in clinical supervision training.
At this time, one training is being offered and clinical supervisor is unable to attend this specific date. Clinical supervisor will seek out another available training and attend the earliest one possible.
Clinical supervisor will report to the regional director to confirm when the training has been scheduled and completed.
In the future, all Clinical Supervisor candidates will receive the Core Curriculum Training, when applicable, prior to promotion to the position. |
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 April 12, 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 record, #6.
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 in 4 PA Code 255.5.
Client #1 was admitted on 1/6/17 and was an active client at the time of the licensing inspection. A consent to release to a person dated 1/26/17 did not specify the purpose of the information to be disclosed.
Client #6 was admitted on 7/29/16 and was discharged on 12/7/16. "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company " dated 7/29/16. Additionally, there was no valid consent to the client's funding source and a consent to release information dated 7/29/16 did not identify the person or agency to whom the information was to be disclosed.
This is a repeat citation.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinician will have client #1 redo consent forms, indicating the purpose of the information to be disclosed.
All Rehab After Work Pottstown Clinicians will attend a training on May 2, 2017 to review proper completion of releases, specifically pertaining to the purpose of the release of information, to whom the information is being releases, and the appropriateness of the information being released. All old versions of the "financial responsibility & authorization" form will be immediately removed from copies of the intake packet by the clinical site supervisor and replaced with the new version that omits the "Clients medication" and "other pertinent information in order for my insurance company to grant authorization of my attendance" which makes this form in compliance with the 4 PA Code 255.5.
All active client charts with the old version of the "financial responsibility & authorization" form will be replaced and resigned by client and clinician by May 15, 2017.
Periodic Chart Audits, in addition to quarterly audits, will be done throughout the year to ensure releases are being completed appropriately and ensure the use of the 4 PA 255.5 compliant financial responsibility et. al. form.
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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 April 12, 2017. The facility failed to update the treatment plan every 60 days in client records, #2, 5, & 6.
Client #2 was admitted on 11/22/16 and was an active client at the time of the licensing inspection. A treatment plan update was created on 1/17/17. Treatment plan update was due by 3/17/17 but was not documented at the time of the licensing inspection.
Client #5 was admitted on 11/8/16 and was discharged on 1/16/17. A comprehensive treatment plan was created on 11/8/16. Treatment plan update was due by 1/8/17 but was not documented at the time of the licensing inspection.
Client #6 was admitted on 7/29/16 and was discharged on 12/7/16. A comprehensive treatment plan was created on 7/29/16. Treatment plan update was due by 9/29/16 but was not documented until 10/3/16. Another treatment plan update was due by 12/3/16 but was not documented at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Client #2 treatment plan was created and filed in client's chart with the appropriate date of 3/17/17, this was completed by 4/28/17.
All Rehab After Work Pottstown Clinicians will attend a training on May 2, 2017 to review proper treatment plan regulations. This training/review will include treatment plan timelines and the requirement of updates every 60 days, master treatment plan collaboration with the client, and updating treatment plans when there is a change in level of care. Clinical supervisor will also review that if a client is still active in treatment, regardless of attendance, a treatment plan update is required every 60 days unless client is discharged prior to timeline.
Periodic Chart Audits, in addition to quarterly audits, will be done throughout the year to ensure treatment plan updates are meeting the timeline regulations of 60 days.
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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
Seven client records were reviewed on April 12, 2017. The facility failed to provide treatment according to the treatment plan in client records, #1, 2, 3 & 5.
Client #1 was admitted on 1/6/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan dated 1/6/17 and a treatment plan update dated 3/6/17 indicated dated indicated IOP group counseling, 4 times per week, however the record of service indicated group was provided on the following dates:
1/9, 1/26, 1/30, 1/31, 2/1, 2/2, 2/6, 2/7, 2/8, 2/9, 2/14, 2/15, 2/16, 2/21, 2/27, 2/28, 3/1, 3/6, 3/13, 3/20, 3/27, 4/3, & 4/10/17.
Client #2 was admitted on 11/22/16 and was an active client at the time of the licensing inspection. The comprehensive treatment plan dated 11/22/16 indicated IOP group counseling, 4 times per week, however the record of service indicated individual counseling was provided on the following dates:
11/29, 11/29, 12/1, 12/6, 12/7, 12/8, 12/13, 12/14, 12/15, 12/19, 12/21, 12/22, 12/28, 12/29/16, 1/3, 1/4, 1/5 & 1/12/17.
Client #3 was admitted on 12/27/16 and was an active client at the time of the licensing inspection. The comprehensive treatment plan dated 12/27/16 indicated IOP group counseling, 4 times per week, however the record of service indicated group was provided on the following dates:
12/28, 12/29/16, 1/3, 1/5, 1/9, 1/10, 1/12, 1/16, 1/17, 1/19, 1/23 & 1/24/17.
Client #5 was admitted on 11/8/16 and was discharged on 1/16/17. The comprehensive treatment plan dated 11/8/16 indicated IOP group counseling, 4 times per week, however the record of service indicated group was provided on the following dates:
11/16, 11/21, 11/22, 11/25, 11/28, 11/29, 12/5, 12/6, 12/9, 12/12, 12/14 & 12/19/16
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
All Rehab After Work Pottstown Clinicians will attend a training on May 2, 2017 to address the appropriate record keeping on the record of service. Every absence needs to be recorded and documented on the record of service, to ensure and document service times are being offered. Clinicians will be directed to start adjusting their records from May 2, 2017 and forward.
Periodic Chart Audits, in addition to quarterly audits, will be done throughout the year to ensure records of service are being documented appropriately.
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