INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on March 24, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab After Work 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 24, 2010.
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Plan of Correction
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document fire extinguisher training within seven days of employment in one of one personnel records.The findings include:Two personnel records were reviewed on March 24, 2010. One personnel record was required to document fire extinguisher training. The facility failed to document the completion of fire extinguisher training within seven days of staff employment in personnel record # 2.Employee # 2 was hired on December 15, 2009. The training was due within seven days, by December 24, 2009. The training was documented on January 15, 2010.
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Plan of Correction
The Site Director of Exton will begin training immediately. All new hires from this point forth will be trained on fire extinguisher use within 7 days of hire, and will be documented appropriately. In regards to current employee, a training will be held to update training from January 2010. All Exton staff are required to attend and sign off that they understand the intent of this standard. |
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 activity. The facility failed to document a financial audit for the 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 arranging 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).
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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.The findings include:Seven client records were reviewed on March 24, 2010. 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 Pa Code 255.5 in client records # 3 and 4. The facility documented the release of substance abuse, current impairments, and current risks in client record #3. The facility documented the release of substance abuse, current impairments, and current risks in client record #4.
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Plan of Correction
The Site Director of exton will begin training immediately. An inservice on the proper way to document informed and voluntary consent will be arranged for 4/7/2010. All staff of exton are required to attend training and sign off that they understand the intent of this standard. The site director will conduct random, monthly chart audits until the office is 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 a document individual treatment and rehabilitation plan in four of seven client records.The findings include:Seven client records were reviewed on March 24, 2010. Individual treatment and rehabilitation plans were required in all seven client records. The facility failed to individualize the treatment and rehabilitation plan in client records # 1, 2, 3, and 4 as they were nearly identical.The facility's policy title "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.Client records #1, 2, 3, and 4 individualized treatment plan document the following.Goal: Client will stop using and understand consequences of use.Objective: Client will work with to understand the severity of his use.Comment: Client also needs positive coping skills to deal with stress, anxiety, and recent adult responsibilities.Action Steps:1. Client will ID 4 consequences of use and 4 benefits of abstinence.2. Client will work to establish a drug free peer group to support his sobriety.3. Client will try to find 3 new activities to try that do not involve drugs.
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Plan of Correction
The Site Director of the Exton office will begin training immediately. An inservice on 4/14/2010 on the proper way to individualize/notate comprehensive treatment/rehabilitation plans will be arranged for 4/14/2010. All staff at the Exton site are required to attend and sign off that they understand the intent of this standard. The Site Director will conduct random, monthly chart audits until the office is in full compliance. |
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 six of seven records.The findings include:Seven client records were reviewed on March 24, 2010. All seven records required a treatment plan with support services. The facility failed to document a treatment plan to include proposed types of supportive services in client records # 1, 2, 3, 4, 5, and 7.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. This 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 # 1, the treatment plan documented on October 8, 2009 contained an action step that stated, "Client will work to establish a drug free peer group to support his sobriety."In record #2, the treatment plan documented on September 12, 2009 contained an action step that stated, "Client will work to establish a drug free peer group to support his sobriety."In record #3, the treatment plan documented on September 30, 2009 contained an action step that stated, "Client will work to establish a drug free peer group to support his sobriety."In record #4, the treatment plan documented on October 28, 2009 contained an action step that stated, "Client will work to establish a drug free peer group to support his sobriety."In record #5, the treatment plan documented on January 15, 2010 did not contain a statement of the type of support services provided or arranged for the patient.In record #7, the treatment plan documented on January 20, 2010 did not contain a statement of the type of support services provided or arranged for the patient.
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Plan of Correction
The site directo of Exton will begin training immediately. An inservice on the proper way to document treatment plans, including proposed support services will be conducted on 4/15/2010. All staff at Exton office are required to attend training and sign off that they understand the intent of this standard. The site director will conduct random audits of charts until the office is in full compliance. |
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 the review of client records, the facility failed to document a complete client record which included an aftercare plan in three of seven client records where required.The findings include:Seven client records were reviewed on March 24, 2010. An aftercare plan was required in three client records. The facility failed to document an aftercare plan in client records # 6 and 7 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. Client #6 was admitted to the program on 12/18/09 and discharged on 1/20/10, aftercare was not documented at the time of review on 3/24/10.Client #7 was admitted to the program on 1/20/10 and discharged on 2/24/10, aftercare was not documented at the time of review on 3/24/10.
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Plan of Correction
The Site Director of Exton will begin training immediately. An inservice on the proper way to document aftercare planning will be arranged for 4/19/2010. All staff of exton office are required to attend training and sign off that they understand the intent of the standard. The site director will conduct random audits of closed charts until the office is in full compliance. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document a complete client record which included a discharge summary in two of seven client records.The findings include:Seven client records were reviewed on March 24, 2010. Five of seven records required documentation of a discharge summary. The facility failed to document a discharge summary in client records #6 and 7.The facility's policy titled "Discharge Documentation" states:Clients choose to leave treatment at different points during their treatment episodes. Some people remain in treatment until they have successfully completed treatment where as other individuals leave treatment Against Medical Advise. Despite the point in time that a person leaves treatment appropriate documentation of their discharge is required. Within seven days of discharge from the program, a discharge summary is entered in the record.Client #6 was admitted to the program on 12/18/09 and discharged on 1/20/10, but a discharge summary was not documented at the time of review on 3/24/10.Client #7 was admitted to the program on 1/20/10 and discharged on 2/24/10, but a discharge summary was not documented at the time of review on 3/24/10.
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Plan of Correction
The Site Director of Exton will begin training immediately. An inservice on the proper way to document discharge paperwork will be scheduled for 4/19/2010. All staff at Exton site are mandated to attend inservice, and sign off that they understand the intent of the standard as well as the parameters of the standard. The Site Director will conduct random chart audits of closed charts until the office is in full compliance. |
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 four of five client records.The findings include:Seven client records were reviewed on March 24, 2010. Five of the seven records required documentation of follow-up information. The facility failed to document follow-up within one week from the date of discharge, as per facility policy in client records # 3, 4, 6, and 7.The facility's policy titled "Follow-up Information" state: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 on e of the following areas located on the chart:1. At bottom left section of the Record of Service - under additional notes section2. On right side of the Record of Service - under notes column 3. Or documented in the discharge summary section of the chart.Client record #3 was admitted to the program on 9/29/09 and discharged on 2/10/10, but follow-up was not documented at the time of review on 3/24/10.Client record #4 was admitted to the program on 10/28/09 and discharged on 2/3/20, but follow-up was not documented at the time of review on 3/24/10.Client record #6 was admitted to the program on 12/18/09 and discharged on 1/20/10, but follow-up was not documented at the time of review on 3/24/10. Client record #7 was admitted to the program on 1/20/10 and discharged on 2/24/20, but follow-up was not documented at the time of review on 3/24/10.
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Plan of Correction
The Site Director of the Exton office will begin training immediately. An inservice on the proper way to administer and document follow-up information after discharge will be held on 4/26/2010. All of the staff of the Exton office are mandated to attend and sign off that they understand the standard. The site director will conduct random, monthly chart audits until the site is in full compliance. |