INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10, 2008 through June 11, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Lower Merion Counseling Services 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 July 11, 2008.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to document a complete staff development policy and procedure. The policy and procedure for staff development did not include a time frame for the completion of the assessment of staff training needs and the overall training plan. The policy did not address who would be responsible for the completion of the annual evaluation of the overall training plan.
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Plan of Correction
The director will develop a comprehensive staff development policy and procedures for agency personnel. The policy and procedures will include a time frame for the completion of the assessment of staff training needs and identify the director as the person responsible for completion of the annual evaluation of the overall plan. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel and training records, the facility failed to have at least one person certified in CPR during the project's hours of operations. No one was certified at the time of the inspection.
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Plan of Correction
The director will make sure that at least one person on site at all times is trained in CPR and first aid. Seven staff were trained in CPR on 7/17/2008.
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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the annual report, the facility failed to document a financial statement of income and expenses for fiscal year 2006/2007.
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Plan of Correction
The director will move the financial statement for the fiscal year 2006/2007 so that it is not separated by a divider from the rest of the director's report. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the annual report, the facility failed to document the names of the directors of the governing body for the fiscal year 2006/2007.
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Plan of Correction
The director will move the names of officers and directors so that they are not separated by a divider from the rest of the director's report.
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures regarding confidentiality for drug and alcohol clients. The facility had a confidentiality policy in place, but it only addressed mental health clients.
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Plan of Correction
The director will revise the policy and procedures so that they are consistent with the state guidelines for confidentiality for drug and alcohol clients(4 Pa.Code 255.5). |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of the policy and procedure manual and client records, the facility failed to obtain an informed and voluntary consent in four of eight records reviewed, #2, 3, 4 and 7.
The specific information to be disclosed to probation exceeded the limitations imposed by 4 Pa. Code 255.5 in record #2. The consent form allowed for the client's psychiatric evaluation to be disclosed.
The specific information to be disclosed to children and youth and probation exceeded the limitations imposed by 4 Pa. Code 255.5. The consent form allowed for the client's
social history, discharge summaries, progress notes, psychiatric evaluations reports, psychiatric test and physical examination to be disclosed in record #3.
The specific information to be disclosed to probation exceeded the limitations imposed by 4 Pa. Code 255.5. The consent form allowed for the client's "social history" and "other" in record #4.
The specific information to be disclosed to Magellan exceeded the limitations imposed by 4 Pa. Code 255.5. The consent form allowed for the client's "assessments, treatment plans, treatment history and other" in record #7.
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Plan of Correction
The director will train staff in the weekly staff meeting and in individual supervision on the limits of the informed consent with drug and alcohol clients as described in 4 Pa.Code 255.5, specifically the limits of information that can be shared with the probation officer, with children and youth staff and with Magellan. There will be quarterly review of charts by the CQI team to ensure that the consent is in compliance |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluations in eight of eight records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8. The psychosocial evaluation was missing in one record, #6. Psychosocial evaluations did not include an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the client's attitude toward treatment in seven records reviewed, #1, 2, 3, 4, 5, 7 and 8.
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Plan of Correction
The director will train all staff on fully completing all components of the psychosocial evaluation including an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the client's attitude toward treatment. The CQI team will examine charts on a quarterly basis to make sure these areas are filled in. Further training will be provided on an as needed basis. |
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 in eight of eight records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8. Treatment plans were not documented.
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Plan of Correction
The director will train staff in individualizing treatment plans and change the format of the Initial Treatment Plan so that it encourages staff to individualize goals. This training will occur in staff meetings. Charts will be checked quarterly by the CQI team. Further training will be provided on an as needed basis by the director or the assistant director.
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709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document a treatment plan that included goals stated in terms of measurable criteria in eight of eight records reviewed, #1, 2, 3, 4, 5, 6, 7, and 8. Treatment plans were not documented.
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Plan of Correction
The director will train staff in working with clients to have measurable goals. This training will occur in staff meetings. The CQI team will meet quarterly to check charts to see that there are measurable goals. Further training will be provided by the director or assistant director on an as needed basis.
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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the treatment plans that included the type of frequency of treatment and rehabilitation services in eight of eight records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
The director will train staff in staff meetings on including in treatment plans the type and frequency of treatment and rehabilitation services.
The CQI team will meet quarterly to review charts to make sure that these items are documented. Further trainings by the director or assistant director will be provided on an as needed basis.
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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 a review of client records, the facility failed to document treatment plans that included the proposed type of support services in eight of eight records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
The director will train staff in staff meetings to include types of support services in treatment plans. The CQI team will meet quarterly to make sure this information is filled in. Further training will be provided by the director or assistant director on an as needed basis.
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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
Based on a review of client records, the facility failed to document complete treatment plan updates in five of seven records reviewed, #1, 2, 4, 6 and 8. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the treatment plan.
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Plan of Correction
The director will train staff in staff meetings to include in all treatment plans an assessment of the client's progress in relationship to the stated goals of the treatment plan. The CQI team will review charts on a quarterly basis to ensure that the client's progress is documented in the treatment plans. Further training will be provided by the director or assistant director on an as needed basis. |
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 a review of client records, the facility failed to document follow-up information in two of four discharge records reviewed, #5 and 6. Follow-up information was missing in one record, #5. Follow-up information was not documented within the facility's identified time frame in one record, #6. The facility's policy and procedure stated that all follow-up information would be documented within 30 days after clients discharge date. Client #6 was discharged 2/6/08 and the follow-up information was not documented until 4/28/08.
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Plan of Correction
The director will amend the follow-up policy to extend the time frame to 60 days and remind staff in a memo to send out the follow up letter within that time frame. The CQI team will meet on a quarterly basis to review random closed charts to ensure that the follow up letter is sent out within the time frame specified by the policy.
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of the facilities policy and procedure manual, the facility failed to have a signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Plan of Correction
The director will send out a letter to the director of the Department of Public Welfare with the goal of having a signed provider agreement on file. This agreement will be renewed every two years.
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