INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 8, 2012 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:
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Plan of Correction
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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 facility policy and procedure manual, the facility failed to document a confidentiality policy and procedure compliant with 4 Pa. Code subsection 255.5. The findings included:4 Pa. Code subsection 255.5 (a)(6), states: "Projects may disclose with the consent of a client, in writing, the information to employers of a client to further the rehabilitation of a client; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Such information shall be limited to whether the client has or is receiving treatment with the project."The facility policy and procedure manual was reviewed as part of the annual onsite licensing inspection of March 5 - 6, 2012. Policy # 60,006, section C, subsection 2, letter f, exceeded 4 Pa. Code subsection 255.5 (a)(6), as it allowed for the following: "Life Management may disclose with the client's consent, the information to employers of a client to further the client's rehabilitation; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Information released shall be limited to that provided for in subsection 4.a. in this section."Subsection 4.a. states: " Nature of Client Information to be Disclosed. a. Information released to judges, probation or parole officers, insurance company, health or hospital plan or government officials, pursuant to section C.2.a-i of this section, is for the purpose of determining the advisability of continuing th client in treatment with Life Management and shall be restricted to the following: i. Whether or not the client isn't in therapyii. The prognosis of the clientiii. The nature of the projectiv. A brief description of the client's progressv. A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse."The project's Confidentiality policy permits for the release of information under ii, iv, and v, which is restricted under 4 PA Code 255.5(a)(6).
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Plan of Correction
The Executive Director of Rehab After Work will change the policy and procedures section in our manual (#66006) to relfect that "information specifically released to employers will be limited to whether a client has or is receiving treatment with the project." This will be circulated to all offices.
All staff will be required to attend a 6 hour training on Confidentiality (255.5) on 4/13/2012 presented at the Phoenixville location. This policy addendum will be reviewed for all staff as part of the training.
Site Directors will perform random, monthly chart audits to ensure that this policy change is being implemented, and reflected by all clinicians. |
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 and the facility's policies and procedures, the facility failed to document a treatment plan update that included the clients' progress on their goals.The findings include:On March 8, 2012 five client records were reviewed for treatment plan updates. Four out of five client records lacked documentation of the client's progress on goals, specifically client records #1, 2, 3, and 5. Client #1 was admitted on December 9, 2011, the treatment plan was completed on December 16, 2011. The treatment plan update dated February 6, 2012 did not include the client's progress on goals. Client #2 was admitted on November 18, 2011, the treatment plan was completed on November 18, 2011. The treatment plan update dated January 18, 2012 did not include the client's progress on goals. Client #3 was admitted on June 24, 2011 and discharged on September 13, 2011. The treatment plan was completed on June 24, 2011. The treatment plan update dated August 23, 2011 did not include the client's progress on goals. Client #5 was admitted on September 19, 2011 and discharged on January 20, 2012. The treatment plan was completed on September 19, 2011. The treatment plan update dated December 19, 2011 did not include the client's progress on goals. The findings were confirmed with the Cite Director during the exit interview.
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Plan of Correction
Training will begin immediately and will be ongoing. The site director of the Exton office will review policy regarding the completion of treatment plan updates in a staff training on 4/11/12. All counselors will participate in the training and sign off that they understand the guidelines regarding treatment plan updates.
The site director will follow up with monthly, random chart audits to ensure that the standard is being met. Charts audits will be ongoing until the center is in full compliance.
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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 and the facility's procedures, the facility failed to document a follow-up in accordance with the project ' s procedures.The findings include:In reference to follow-ups the project states: A follow up is to be documented in 7 days for all clients, regardless of discharge status. On March 8, 2012 one client record was reviewed for documentation of a follow-up. One out of one client record lacked documentation of a follow-up, specifically client record # 4. Client #4 was admitted on June 22, 2011 and discharged on October 29, 2011. A follow-up was due to be documented by November 5, 2011, as of the date of the inspection, there was no follow-up documented for client # 4. The findings were confirmed with the Cite Director during the exit interview.
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Plan of Correction
Training will begin immediately and will be ongoing. The site director of the Exton office will review policy regarding the completion of follow-ups in a staff training on 4/18/12. All counselors will participate in the training and sign off that they understand the guidelines regarding follow-ups.
The site director will follow-up with monthly, random chart audits to ensure that the standard is being met. Charts audits will be ongoing until the center is in full compliance.
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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, a visitor ' s inquiry, and a statement from the Site Director, the project failed to provide clerical and other support staff in sufficient numbers to insure efficient operation of all of the services provided by the project.The findings include: On March 8, 2012 the Staffing Requirements Facility Summary Report was reviewed. When the inspector inquired why there was no support staff listed on page 7, the Site Director advised they do not employ clerical or support staff and the clinical team handles all of the facility ' s tasks. At approximately 11:52 am, a woman entered the facility and asked this inspector for information about the program as she was interested in obtaining services. She was advised that no one was available but if she waited a few moments the program ' s staff would return or she could leave her information and someone would get back to her. She declined and advised she would return at a later time. This was confirmed with the Site Director at approximately 12:20pm and again during the exit interview.
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Plan of Correction
Effective immediately the site director of the Exton office will thoroughly review all staff schedules to ensure that there is appropriate number of staff present to accomodate all client traffic. In addition,the site director of Exton will investigate installation of audio alert (i.e. bell or chime) that will notify staff of client's presence (entrancee/exit). The site director of Exton will document progress monthly in directors log. |