INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the February 17, 2011 licensure renewal inspection. The follow-up inspection was conducted on August 29, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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.
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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 a review of the "Staffing Requirements Facility Summary Reports" completed by each facility in the Project, and based on a conversation with the Project Director, 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:The "Staffing Requirements Facility Summary Report" for each of the thirteen facilities that make up the Project was reviewed. The "Staffing Requirements Facility Summary Reports" completed by the facilities on August 11, 2011 list a combined total of 37 counselors and 13 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 42.3 FTE counselors within the project, and therefore the project is required to have at least five 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. The Project Director confirmed during the follow-up inspection on August 11, 2011 that the Project did not have a full-time clinical supervisor for every eight full-time counselors in the Project. The Project Director stated "the Project is financially incapable of hiring a full-time clinical supervisor" for every eight full-time counselors or counselor assistants.This is a repeat citation. The facility was previously cited for noncompliance on February 11, 2011.
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Plan of Correction
The Executive Director of Rehab After Work is currently awaiting response from the state submitted on 9/16/11 regarding an exception for the Clinical Supervisor staffing requirement. If exception is not granted, the Executive Director will need to re-structure current clinical supervision procedures by adding salaried/benefit eligable full-time clinical supervisors as per state regulations. The Executive Director will need to obtain Governing Body approval to re-organize salary structures and potentially downsize by closing smaller offices. |
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.This was still out of compliance at the time of the follow-up inspection conducted on August 29, 2011.
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Plan of Correction
The Site Director will have staff training reviewing All mandatory Trainings required by the state (ex. STD/TB, HIV/AIDS) The staff will be informed of the minimum 25 clock hours of training required per year. The site director will check clinicians hours quarterly to monitor 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 a review of administrative documentation and a conversation with the Project 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:During the follow-up inspection at the administrative site which was conducted on August 11, 2011 the project remained out of compliance as Rehab Management Inc. failed to document an annual financial audit by 6/30/11 as indicated in the plan of correction which was approved on 4/8/11. In addition, On February 11, 2011 the project's administrative records were reviewed for a financial audit following the end of their fiscal year. The project's 2009 fiscal year ended on December 31, 2009, but the independent financial audit for this period was not documented at the time of review. The facility was still out of compliance with not having completed a copy of the 2009 financial audit.This is a repeat citation. The facility was cited on March 3, 2010 and February 11, 2011 for failing to document an annual financial audit.
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Plan of Correction
The current audit has been completed as of 9/23/11 and finalized results have been placed in the Governing Body Minutes located at the Paoli location. The Executive Director of Rehab After Work has made arrangements with the auditor to ensure that future audits will be completed in a timely fashion in accordance with state guidelines |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this follow-up licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.The findings include: On August 11, 2011, at the administrative site inspection, the facility was again found to be out of compliance with the following standards: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. This area of noncompliance was also identified during the March 3, 2010 (plan of correction submitted on 3/29/10 and approved on 3/29/10) and February 11, 2011 (plan of correction submitted on 4/7/11 and approved on 4/8/11) licensing inspections.
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Plan of Correction
The Executive Director of Rehab After Work is currently awaiting response from the state submitted on 9/16/11 regarding an exception for the Clinical Supervisor staffing requirement. If exception is not granted, the Executive Director will need to re-structure current clinical supervision procedures by adding salaried/benefit eligable full-time clinical supervisors as per state regulations. The Executive Director will need to obtain Governing Body approval to re-organize salary structures and potentially downsize by closing smaller offices.
The current audit has been completed as of 9/23/2011 and finalized results have been placed in the Governing Body Minutes located at the Paoli location. The Executive Director of Rehab After Work has made arrangements with the auditor to ensure that future audits will be completed in a timely fashion in accordance with state guidelines
Completion Date:
12/30/2011
Status:
Submitted
Date:
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