INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 17, 2011 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 March 29, 2011.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on the review of the " Staffing Requirements Facility Summary Reports " completed by each facility in the Project, and based on interviews with each facility director in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.The findings include:From February 10 through March 3, 2011, the " Staffing Requirements Facility Summary Reports " for each of the thirteen facilities that make up the Project were reviewed. The " Staffing Requirements Facility Summary Reports " list a combined total of 41 counselors and 12 facility directors who are providing drug and alcohol counseling. The total number of drug and alcohol counseling hours per week provided by the counselors and facility directors equates to 39.6 FTE counselors within the project, and therefore the project is required to have at least four full-time clinical supervisors and one part-time clinical supervisor or lead counselor. The " Staffing Requirements Facility Summary Reports " did not identify a full-time clinical supervisor at any of the Project ' s thirteen facilities. From February 10 through March 3, 2011, interviews with each facility director in the Project were conducted during their respective licensing inspection. Each facility director confirmed that the Project does not have a full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
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Plan of Correction
Rehab After Work will submit a request for appeal. If we are not granted the appeal, the Project Director will ensure that there is one full time clinical supervisor for each eight FTE. |
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 the review of personnel records and an interview with the facility director, the facility failed to document at least 25 clock hours of training annually in one of four personnel records.The findings include:On February 17, 2011 four personnel records identified as counselors during the 2010 training year were reviewed for documentation of 25 clock hours of training. The facility did not document 25 hours of training during the 2010 training year in personnel record # 5.Personnel record #5 documented only 15 hours of training for the 2010 training year.An interview with the facility director on February 17, 2011, confirmed that personnel record #5 did not contain at least 25 hours of training for the 2010 training year.
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Plan of Correction
The site director will have a staff training reviewing all mandatory trainings required by state(ei. STD/TB, HIV/AIDS) Will inform staff of minimum 25 hour clock hours of training required per year. The site director will check clinicians hours quarterly to see status and ensure correction for 2011. |
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 records and an interview with the facility director, the Project failed to document an independent annual audit of financial activities associated with the Project's drug/alcohol abuse services.The findings include:On February 10, 2011 the Project ' s administrative records were reviewed for a financial audit following the end of their fiscal year. The Project ' s fiscal year ended on December 31 2009, but the independent financial audit for this period was not documented at the time of review. An interview with the facility director on February 10, 2011 confirmed that the financial audit had not been documented following the end of the fiscal year.This is a repeat citation. The facility was cited on March 9, 2010 for failing to document an independent financial audit.In response to the citation issued on March 9, 2010, the facility provided the following plan of correction: The executive director shall submit a written request within 90 days for a 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 the area on a monthly basis and note progress in the governing body minutes (manual). The facility indicated that they would be in compliance with the standard by 6/30/2010. The facility's exception request as presented, and received on August 25, 2010 was denied. A letter explaining the reason for denial was sent to the facility on September 15, 2010.
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Plan of Correction
The Project Director will acquire the services of a certified public accountant to do an independent audit and include an opinion page for last fiscal year and each fiscal year to follow. The Project Director will ensure these are done on an anual basis. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document a fingerprint based national criminal history record check in three of three records. The findings include:Based on the Child Protective Services Law (CPSL) Act 73, anyone hired after June 30, 2008, engaging in an occupation with a significant likelihood of regular contact with children, must have a fingerprint based national criminal history record check. Because this facility has adolescent clients, staff hired after June 30, 2008 would have to comply with this requirement.On February 17, 2011 one personnel records was reviewed for a fingerprint based national criminal history record check. The facility did not document a fingerprint based national criminal history record check in personnel record #6. Personnel #6 was hired after June 30, 2008, and because he is engaging in an occupation with a significant likelihood of regular contact with children, he is required to have a fingerprint based national criminal history record check.Personnel #6 was hired in December 2008, but the fingerprint based national criminal history record check was not documented at the time of inspection.An interview with the facility director on February 17, 2011 confirmed that personnel record #7 did not contain a fingerprint based national criminal history record check.
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Plan of Correction
The site director will distribute FBI clearance forms for each staff member hired after July 1st 2008. Will also make sure for any new hire. The site director will have clinician get prints done and monitor progress wich can take 2 to 4 weeks for processing time. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of client records, and an interview with the facility director, the facility failed to document progress notes in three of six records. The findings include:On February 17, 2011, six client records were reviewed for progress notes. The facility did not document progress notes to include data, assessment and plans relative to treatment in client records # 2, 3 and 4. In client record #2, the assessments and the plans were identical for the individual session progress notes documented on November 2, 24, December 1, 8, 22, January 5, 11, 19 and February 2. In client record #3, the individual session progress notes documented on January 12, 13, 23, 27, February 3 and 17 were illegible. In client record #4, the assessments and the plans were identical for the individual session progress notes documented on December 6, 8, 11, 29, January 3, 10, 24, 31 and February 7.An interview with the facility director on February 17, 2011 confirmed that the identified progress notes contained identical plans and the assessments, or were illegible.
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Plan of Correction
The site director will have a training with all staff reviewing state regs and results with in one month from today. The site director will review how to write a DAP form progress note. We will discuss what is expected in the content of Data, Assessment and Plan that is written in the note. Site director will randomly check charts quarterly and specifically monitor the content of the DAP notes and document progress on the quarterly review form. |