INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2009 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 28, 2009.
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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 document the Department provided core curriculum in clinical supervision for supervisors who have not functioned for two years as supervisors in the provision of clinical services.
Findings:
Six personnel records were reviewed on March 25, 2009. A core curriculum in clinical supervision was required in one personnel record. The facility did not document the core curriculum in personnel records # 2.
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Plan of Correction
The site director of Center City will provide an updated resume that reflects training in the core curriculum in clinical supervision from 2003 - 2005. A copy will be placed in the personnel file by 4/21/09.
The site director at Center City will obtain BDAP Clinical Supervision 5-day training at the next time it is provided |
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, the facility failed to document a minimum of 4 hours of tuberculosis/STD training in one of six personnel records.
Findings:
Six personnel records were reviewed on March 25, 2009. 4 hours of tuberculosis/STD training were required in six personnel records. The facility did not document 4 hours of Tuberculosis/STD training in personnel record # 4.
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Plan of Correction
The site director of Center City will meet with counselor #4 to insure that she successfully completes a four hour tb/std trainig on 6/8/09. Counselor #4 will provide verification that she attended this training and the site director will put the certificate in her personnel file |
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 seven client records.
Findings:
Seven client records were reviewed on March 25, 2009. Documentation of informed and voluntary consent from the client for the disclosure of information was required in seven client records. The facility did not document informed and voluntary consent from the client for the disclosure of information in client records # 3 and 4.
The facility documented the release of client information to an insurance company, but the information released exceeded the limitations of 4 Pa Code 255.5 in client records # 3. The facility documented the release of treatment notes, treatment plans, diagnostic test results and procedure reports in client record # 3.
The facility documented the release of client information to a laboratory, but a signed consent from the client for the release of information was not documented in client records # 4.
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Plan of Correction
The site director of center city will conduct an inservice training on 4/29/09 for the counselors of client records #3 and #4 to review documentation regarding informed and voluntary consent for the disclosure of information contained in client records. The counselors will sign off that they attended this training and will understand the intent of the documentation. The site director of center city will perform monthly random chart audits until the counselors are in full compliance. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan developed with the client in three of four client records.
Findings:
Seven client records were reviewed on March 25, 2009. Individual treatment plans were reviewed in four client records. The facility did not document an individual treatment plan developed with the client in records # 2, 3 and 4.
The treatment plans were not signed by the client, and there was no documentation, in the client ' s progress notes, to indicate the client participated in the development of the treatment plan.
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Plan of Correction
The site director of center city will train all clinical staff to have the client sign their master treatment plan or document in the chart that counselor met with client individually to develop the treatment plan. This training will be done by 4/22/09. All staff will sign off that they attended the training and understand the intent of this documentation. The site director of center city will perform random monthly chart audits until there is 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 in three of three client records.
Findings:
Seven client records were reviewed on March 25, 2009. A treatment plan update was required in three client records. The facility did not document a treatment plan update in client records # 1, 3 and 4.
Treatment plan updates did not include an assessment of the client ' s progress in relationship to the stated goals of the master treatment plan in client records # 1, 3 and 4.
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Plan of Correction
The site director of center city will have an inservice training with all staff on completion of treatment plan updates by 4/22/09. All staff will sign off that they attended the training and understand the intent of this documentation. The site director will do random monthly chart audits until the center is in full compliance |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on a review of client records, the facility failed to document a medication record in three of four client records.
Findings:
Seven client records were reviewed on March 25, 2009. A medication record was required in four client records. The facility did not document a medication record in client records # 1, 4 and 5.
Client record #1 documented Metroprolo, Norvasc, Accupril and Vytorin prescribed, but the record did not document the dosage of these medications.
Client record #4 documented medications prescribed, but the record did not document the name, dosage and frequency of these medications.
Client record #5 documented Benicar prescribed, but the record did not document the dosage of this medication.
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Plan of Correction
The site director of center city will conduct an inservice training on how to document the name, dosage and frequency of medication in the client record. The training will be conducted on 4/22/09. All staff will sign off that they attended this training and understand the intent of the documentation. The site director will conduct random monthly chart audits until the center is in full compliance |