INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on March 22, 2010 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 20, 2010.
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Plan of Correction
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of administrative documentation and an interview with the project director, both occurring on March 2, 2010, the facility failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility's administrative documentation was reviewed and an interview with the project director was conducted on March 2, 2010. The facility was required to document an annual audit of financial activities. The facility did not document a financial audit for 2008-2009 fiscal year.
The project director confirmed that a financial audit had not been completed.
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Plan of Correction
The Executive Director shall submit a written waiver of this regulation.If the waiver is not granted then the Executive Director of Rehab After Work will begin the process of aranging for an independent, external audit with approval from the Governing Body president. The Executive Director will monitor progress in this area on a monthly basis and note progress in the Governing Body minutes (manual). |
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 a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in three of eight client records.
The findings include:
Seven client records were reviewed on March 22, 2010. Counseling services provided according to the individual treatment and rehabilitation plan were required in all records reviewed.
The facility failed to document, either in the record of service or progress notes, that counseling services were provided according to the individual treatment and rehabilitation plan in client records #5, 6, and 7.
Group sessions were prescribed four times per week in treatment plan update 9/2/09 for client #5. The facility documented group sessions for client #5 on 9/2/09, 9/9/09, 9/14/09, 9/19/09, 9/21/09, 9/28/09, 10/5/09, 10/19/09, 10/26/09, 10/28/09, and 10/31/09.
Individual sessions were prescribed weekly in treatment plan dated 12/7/09 for client #6. The facility only documented individual sessions for client #6 on 12/7/09, 12/23/09, 1/7/10, 1/13/10, 1/21/10, 1/25/10, 2/1/10, 2/15/10, 2/25/10, and 3/10/10. The facility documented call out for client #6 on 12/14/09.
Weekly sessions were prescribed in treatment plan update 11/7/09 for client #7. The facility only documented sessions for client #7 on 11/9/09, 11/23/09, 12/7/09, and 12/28/09.
Weekly sessions were prescribed in treatment plan update 1/7/10 for client #7. The facility only documented sessions for client #7 on 1/18/10, 1/25/10, 2/22/10, and 3/1/10.
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Plan of Correction
The Site Director of Havertown will conduct an in-service training to inform all staff that client records must reflect the services to be performed which are stated in the individual treatment and rehabilitation plans are documented on the records of service or the progress notes. This requirement applies to both individual and/or group sessions. The Site Director of Havertown will conduct monthly chart audits to ensure that this standard is in full compliance
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document a complete client record which included an aftercare plan in one of three client records where required.
The findings include:
Seven client records were reviewed on March 22, 2010. An aftercare plan was required in three client records. The facility failed to document an aftercare plan in client record #3 within one month of the scheduled discharge date, as per facility policy.
The facility's policy titled Continuing Care Plan states:
The final phase of treatment is aftercare planning. In accordance with a relapse prevention philosophy, RAW policy requires that patients develop an effective detailed plan for maintenance of sobriety after completing the program. The primary counselor is responsible for meeting with the patient to develop a detailed Continuing Care Plan for the patient to follow after they leave formal treatment. The Continuing Care Plan is completed within one month of the scheduled discharge date in the context of ongoing individual counseling sessions. The Continuing Care Plan is completed and signed by the patient and counselor before anticipated discharge. The Continuing Care Plan should focus on the patient's long term goals and objectives with a focus on sustaining and building on the progress achieved during treatment....
Continuing Care Plans are not required where patients have left treatment against advice or refused to participate in an aftercare plan. Plans are also not required if a patient is being referred to another facility for further treatment. Follow-up on the referral is documented in the patient record.
Client #3 was admitted to the program on July 8, 2009 and discharged on October 9, 2009,. The facility did not provide documentation of an aftercare plan at the time of review on March 22, 2010.
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Plan of Correction
The Site Director of Havertown will conduct an in-service training to inform all staff that it is required that all client records must have aftercare plans completed within one month of discharge. Primary counselors are to meet with the client to develop a detailed Coninuing Care Plan for the client to follow after they leave formal treatment. The Site Director of Havertown will conduct monthly chart audits to ensure that this standard is in full compliance |