INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 8, 2008 through December 11, 2008 and December 16, 2008, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Riverside Care, 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 January 15, 2009.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the 25 clock hours of training annually for each counselor.
Findings:
Seven personnel records were reviewed on December 9, 2008. Documentation of 25 clock hours of training annually for each counselor was required in two employee records. The facility failed to document the 25 clock hours of training annually for one of two employee records. Employee #5 only had 15 hours of training documented.
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Plan of Correction
Clinical Supervisor will schedule and monitor all clinicians attendance at trainings throughout the training year. Clinical Supervisor will obtain training certificates to ensure that 25 hours of training obtained by each clinician. |
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 for each client which allows the client the opportunity to revoke the consent both verbally and in writing.
Findings:
Fourteen client records were reviewed on December 16, 2008. Documentation of informed and voluntary consent was required in nine client records. The facility failed document within the "Authorization and Written Consent for Disclosure of Health Information" the client's right to verbally revoke the consent in two of nine client records, #1 and 2.
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Plan of Correction
Director of Clinical Services will restructure release of information form to include regulatory revocation standards. All staff will be trained on release of information form, policies and regulations by Program Director. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document disclosure to the client of criteria for admission, treatment, completion, and discharge for each client.
Findings:
Fourteen client records were reviewed on December 16, 2008. Documentation disclosure to the client of criteria for admission, treatment, completion, and discharge was required for nine client records. The facility failed to document disclosure to the client of criteria for admission, treatment, completion, and discharge in nine of nine client records, # 1, 2, 3, 4, 5, 6, 7, 8, and 9.
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Plan of Correction
Orientation to treatment includes criteria for admission, treatment, completion and discharge. Orientation to treatment form is part of general intake packet in electronic record system. Administrative staff to complete packet with all incoming clients. Clinical Supervisor will ensure documentation through reviewing all intake documentation weekly. |
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 that treatment and rehabilitation plans were reviewed and updated at least every 60 days for each client.
Findings:
Fourteen client records were reviewed on December 16, 2008. Documentation that treatment and rehabilitation plans were reviewed and updated at least every 60 days was required in nine client records. The facility failed to document that treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of nine client records. For client record #6, the treatment plan update due September 29, 2008 was not documented. For client record #7, the treatment plan update due October 10, 2008 was not documented. For client record #8, the treatment plan updates due July 17, 2008 and September 17, 2008 were not documented.
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Plan of Correction
The Clinical Supervisor will utilize electronic record reports to determine when treatment plans are due and develop tracking system. Clinical Supervisor will monitor through biweekly supervision with clinicians and review and sign all treatment plans. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultation notes on a quarterly basis for each client.
Findings:
Fourteen client records were reviewed on December 16, 2008. Documentation of case consultation notes was required in nine client records. The facility failed to document case consultation notes on a quarterly basis for three of nine client records, #7, 8, and 9.
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Plan of Correction
Clinical Supervisor will develop a system to keep track of case consultation due dates. Clinical Supervisor is responsible for completion of all case consultations, minimally every 90 days. Monitor through bi-weekly supervision by Clinical Supervisor. |
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 a review of client records, the facility failed to document a discharge summary for each client within seven days following discharge.
Findings:
Fourteen client records were reviewed on December 16, 2008. Documentation of a discharge summary completed with seven days of the client's discharge was required in seven client records. The discharge summary was documented as completed beyond seven days past the client's discharge from the facility in four of seven client records. For client record #9, the discharge summary was due by October 23, 2008, but was not documented as complete until December 15, 2008. For client record # 12, the discharge summary was due by July 31, 2008, but was not documented as complete until October 28, 2008. For client record #13, the discharge summary was due by October 27, 2008, but was not documented as complete until December 4, 2008. For client record #14, the discharge summary was due by October 15, 2008, but was not documented as complete until December 4, 2008.
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Plan of Correction
Clinical Supervisor will utilize electronic chart reports to monitor upcoming discharges. Clinical Supervisor responsible for completion of discharge summaries within 7 days of client discharge. Monitor through bi-weekly supervision by Clinical Supervisor. |