INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on March 8-9, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection,Rehab Management Inc 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 1, 2010.
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the staffing requirements facility summary report form completed by the facility on March 8, 2010 and an interview with the facility director, the facility failed to ensure that counselor outpatient caseloads were at or below 35 active clients per one FTE counselor.
The findings included:
On March 8, 2010, eleven counselor outpatient caseloads were reviewed on the facility summary report form. Per regulation, the caseload for counseling in outpatient programs may not exceed 35 clients per one FTE counselor. Based on the number of hours worked, and the number of clients on the counselors' caseload, one counselor exceeded the maximum outpatient caseload of 35:1.
Counselor number six had a caseload of 37:1.
The facility director was interviewed on March 9, 2010 at approximately 11:30 AM.
The facility director confirmed that counselor number six was over the required caseload of 35:1.
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Plan of Correction
The acting site director of lansdale will begin training immediately on 3/24/2010 regarding the 35 clients/fte ratio regarding outpatient caseloads with counselor #6 of the lansdale office. Counselor #6 will sign off that they understand this ratio & will not exceed ratio in the future. The site director of lansdale will perform random, weekly client ratio audits on counselor #6 to ensure that the counselor remains in full compliance. |
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, 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 request within 90 days for a waiver of this regulation. If the waiver is not granted, then the executive director of Rehab After Work will begin the process of arranging for an independent, external audit with approval from the governing body president. The executive director will monitor progress in the area on a monthly basis and note progress in the gorverning body minutes (manual). |
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 facility failed to document informed and voluntary consent from the client for the disclosure of information contained in two of thirteen records reviewed.
Findings:
Thirteen client records were reviewed on March 8-9, 2010. Documentation of informed and voluntary consent from the client for the disclosure of information was required in thirteen records. The facility did not document informed and voluntary consent from the client for the disclosure of information in client records #11 and 12.
The facility documented the release of client information to an insurance company on July 27, 2009, July 30, 2009, and September 3, 2009; but the information released exceeded the limitations of 4 Pa Code 255.5 in client record #11.
The facility documented the release of current risks, current impairments, and substance abuse in client record #11.
The facility documented the release of client information to an attorney, but a signed consent from the client for the release of information was not documented in client record #12.
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Plan of Correction
The acting site director of the lansdale office will meet with the counselor of client records #11 & #12 on 3/24/2010 and review the confidentiality guidelines regarding informed and voluntary consent. The counselor of client records #11 & #12 will sign off that they comprehend all standards regarding informed and voluntary consent/releases. The site director of lansdale will conduct random, weekly chart audits to ensure that the counselor is in full compliance with this standard. |
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.
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Observations
Based on the review of client records, the facility failed to document treatment plans to include proposed type of support services in five of thirteen client records.
The findings include:
Thirteen client records were reviewed on March 8-9, 2010. All thirteen records required a treatment plan with support services. The facility did not document a treatment plan to include proposed types of supportive services in client # 4, 5, 8, 11, and 13.
The facility's policy on Comprehensive Treatment Plan states:
The Comprehensive Treatment Plan is an individual treatment and rehabilitation plan developed in collaboration with each patient and their assigned Primary Counselor. The plan shall include, but not be limited to, written documentation of:
1. Short and long term goals for treatment as formulated by both the Primary Counselor and the patient. Goals should be realistic and stated in terms of measurable criteria.
2. Type and frequency of treatment and rehabilitation services.
3. Proposed type of support service. Services may include medical, psychiatric or mental health services, financial, legal, AA, NA, etc.
In record #4, the treatment plan documented on 6-29-09 did not contain a statement of the type of supportive services provided or arranged for the patient.
In record #5, the treatment plan documented on 9-10-09 did not contain a statement of the type of supportive services provided or arranged for the patient.
In record #8, the treatment plan documented on 9-21-09 did not contain a statement of the type of supportive services provided or arranged for the patient.
In record # 11, the treatment plan documented on 7-22-09 did not contain a statement of the type of supportive services provided or arranged for the patient.
In record # 13, the treatment plan documented on 7-23-09 did not contain a statement of the type of supportive services provided or arranged for the patient.
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Plan of Correction
The acting site director of lansdale will ensure that training begins immediately and is ongoing. An initial inservice training on the documentation of support services in the individual treatment plan will be arranged for 4/7/2010. All counselors of the lansdale office will be required to attend the training and sign off that they understand the intent of this documentation. The lansdale site director will perform random, monthly chart audits to ensure that the center is in full compliance. |
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
Based on a review of client records, the facility failed to document a treatment plan update on the client's progress in relationship to the stated goals identified in the individual treatment and rehabilitation plan in six of thirteen records reviewed.
The findings include:
Thirteen client records were reviewed on March 8-9, 2010. Thirteen records required documentation of a treatment plan update that includes an assessment of the client's progress as it relates to the the goals identified in the individual treatment and rehabilitation plan. The facility did not document an assessment of progress in the treatment plan update in client records #1, 2, 7, 8, 9, and 13.
The facility's policy on Treatment Plan Review and update states:
1. The Comprehensive Treatment Plan shall be reviewed and updated at least every 60 days.
2. The Comprehensive Treatment Plan review and update should include an assessment of the patient's progress in relationship to the stated goals of the plan.
The following issues should be considered:
a. How have problems identified in the Comprehensive Treatment Plan been impacted through treatment?
b. Are the Comprehensive Treatment Plans goals and objectives in need of revision?
c. Do the treatment strategies, action steps or modalities need revision?
d. Is closure of treatment goals and objectives noted when goals/objectives are achieved or revised?
Client #1 individual treatment plan was completed on 10-20-09, the update was complete on 12-20-09 and 2-20-10, but did not include an assessment of progress in relation to the stated goals of the individual treatment plan.
Client #2 individual treatment plan was completed on 12-28-09, the update was complete on 2-16-10, but did not include an assessment of progress in relation to the stated goals of the individual treatment plan.
Client #7 individual treatment plan was completed on 10-14-09, the update was complete on 12-14-09 and 2-14-10, but did not include an assessment of progress in relation to the stated goals of the individual treatment plan.
Client #8 individual treatment plan was complete on 9-21-09, the update was complete on 11-16-09 and 1-14-10, but did not include an assessment of progress in relation to the stated goals of the individual treatment plan.
Client #9 individual treatment plan was complete on 11-22-09, the update was complete on 1-12-10, but did not include an assessment of progress in relation to the stated goals of the individual treatment plan.
Client #13 individual treatment plan was complete on 7-23-09, the update was complete on 9-23-09, but did not include an assessment of progress in relation to the stated goals of the individual treatment plan.
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Plan of Correction
The acting site director of lansdale will ensure that training is ongoing & begins immediateley. An initial inservice training regarding the documentation of treatment plan updates will be scheduled for 4/7/2010 for all lansdale counselors. The training will encompass all areas regarding treatment plan updates & staff will sign off that they understand the intent of the regulation. The site director of lansdale will perform random, monthly chart audits to ensure that the center is in full compliance with this standard. |
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.
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Observations
Based on the review of client records, the facility failed to document follow-up information in five of five client records.
The findings include:
Thirteen client records were reviewed on March 8-9, 2010. Five of the thirteen records required documentation of follow-up information. The facility did not document follow-up information within one week from the date of discharge, as per facility policy in client record 4, 5, 11, 12, and 13.
The facility's policy titled "Follow-Up Information" states:
When a patient has been discharged and referred to an outside resource, the Counselor or a designee of the Site Director, with the written consent of the client and within one week from the day the referral is completed, attempts to determine from the resource and/or client the disposition of the referral. The Counselor and/or designee of the Site Director then will document the attempt in at least one of the following areas located on the chart:
1. At bottom left section of the Record of Service-under additional notes section;
2. On right side of the Record of Service- under notes column;
3. Or documented in the Discharge Summary section of the chart
Client # 4 admission date was 6-16-09, the discharged date was 10-27-09, but follow up was not documented at the time of review on March 9, 2010.
Client # 5 admission date was 8-27-09, the discharged date was 12-18-09, but follow up was done late on 1-4-10.
Client # 11 admission date was 7-16-09, the discharged date was 12-21-09, but follow up was not documented at the time of review on March 9, 2010.
Client # 12 admission date was 7-6-09, the discharged date was 11-11-09, but follow up was done late on 11-23-09.
Client # 13 admission date was 7-10-09, the discharged date was 11-12-09, but follow up was done late on 11-23-09.
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Plan of Correction
The acting site director of lansdale will ensure that training is effective immediately & ongoing. An inservice training regarding documentation of follow-up care will be arranged for all counselors of the lansdale site for 3/24/2010. All aspects of follow-up documentation will be reviewed and counselors will sign off that they comprehend the intent of the documentation. The site director will perform random, monthly chart audits too ensure that the regulation is being met & that the center is in full compliance. |