INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2009 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 April 4, 2009.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records on March 3, 2009, the facility failed to document that the facility director meets the experiential qualifications for the position of facility director.
Findings:
Personnel records were reviewed on March 3, 2009. The facility director's resume was reviewed on March 3, 2009. The facility failed to document that employee #2 meets the experiential requirements of two years of experience in a human service agency which includes supervision of others and program planning.
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Plan of Correction
The Executive Director of Rehab After Work will ensure that the Site Director of Havertown location produce an updated resume that reflects thet they have 2 years of experience in a human service agency which includes supervision of others & program planning. This updated resume will be placed in the Site Director's personel file located at the Paoli office. The Executive Director will monitor until in compliance. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel records, the facility failed to document that the facility director/clinical supervisor completed a core curriculum in clinical supervision.
Findings:
Personnel records were reviewed on March 3, 2009. Core curriculum in clinical supervision was required for one employee, #2. Employee #2 did not document in her resume any experience as a supervisor in the provision of clinical services. Employee #2 was hired for the position of facility director, which includes responsibility for clinical supervision, in 7/07. The facility did not document that employee #2 completed a core curriculum in clinical supervision.
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Plan of Correction
The Executive Director of Rehab After Work will ensure that the Site Director of Havertown location produce an updated resume that reflects thet they have completed the core curriculum in clinical supervision. This updated resume will be placed in the Site Director's personel file located at the Paoli office. The Executive Director will monitor until in compliance.
Documentation of the core curriculum in supervision training will be placed in the personnel file of the current Site Director of Havertown. The actual certificate is not available. Any future staff in the position of Site Director, will take the core curriculum in clinical supervsion training provided by the Bureau of Drug and Alcohol Programs. Any new staff in the position providing clinical supervision will take the training in clinical supervision within six months. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 degrees F.
Findings:
The physical plant inspection was conducted on March 10, 2009 between 9:30 and 10:00 AM. The hot water temperature measured 140 degrees F.
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Plan of Correction
The Site Director of Havertown will contact landlord/maintenance of the Falcon Center to correct the water temperature problem at the Havertown office. The landlord/maintenance of Falcon Center will fix the problem and provide documentation that the water temperature was tested & that it does not exceed 120F. The Site Director will monitor the water temprature to ensure that this deficiency does not recur |
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 a review of personnel records, the facility failed to document that all staff were, within seven days of hire, instructed in the use of the fire extinguisher.
Findings:
Five personnel records were reviewed on March 3, 2009. Documentation that staff were instructed in the use of the fire extinguisher was required for one employee. The facility failed to document that employee #4 was instructed in the use of the fire extinguisher within seven days of hire. Employee #4 was hired for the counselor position in November 2008. Documentation was provided that employee #4 was instructed in the use of the fire extinguisher on 1/29/09.
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Plan of Correction
The Site Director of Havertown will meet with employee #4 to document instruction of the use of the fire extinguisher.
Site Director of Havertown will ensure that new hires will be instructed to use fire extinguisher within seven days of hire and documentation will reflect such corrective measures in the personnel record. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel are trained to perform assigned tasks during emergencies.
Findings:
Five personnel records were reviewed on March 3, 2009. Documentation of training to perform assigned tasks during emergencies was required for one employee. The facility failed to document that employee #4 was trained to perform assigned tasks during emergencies within seven days of hire. Employee #4 was hired in November 2008 and the facility documented that employee #4 was trained to perform assigned tasks during emergencies on 1/29/09.
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Plan of Correction
The Site Director of Havertown will meet with employee #4 to document training to perform assigned tasks of emergencies. Site Director of Havertown will ensure that new hires will be instructed perform assigned tasks during emergencies within seven days of hire and documentation will reflect such corrective measures in the personnel record.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records, the facility failed to document that a fire alarm or smoke detector was set off during each fire drill.
Findings:
The fire drill records were reviewed on March 10, 2009. An interview with the facility director regarding the fire drills was conducted on March 10, 2009. The facility failed to document that the smoke detector was set off during each fire drill from 4/08 through 2/09. The facility director stated that the smoke detectors were not set off during the fire drills and that the facility was using an alternate means of announcing the fire drills. The facility director failed to provide documentation that the alternate means was approved by the Department of Health. The facility director also failed to document the annual inspection of the smoke detectors or fire alarms.
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Plan of Correction
The Site Director of the Havertwon office will draft a letter & send to the Department of Health requesting that an alternate means of announcing fire drills can be used. This documentation will be kept in the Site Director's log on location once it is recieved from the state. Also, the Site Director of Havertown will provide documentation that the system is inspected "annually" & this will also be kept in the Site Director's log located at the Havertown office.
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the physical plant inspection, the facility failed to secure client records within locked storage containers.
Findings:
The physical plant inspection was conducted on March 10, 2009 between 9:30 and 10:00 AM. The client records were stored in unlocked cabinets within an unlocked multi-use room.
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Plan of Correction
Site Director of Havertown will ensure that all employees of Havertown will secure client records within locked storage containers at all times.
Site Director of Havertown will perform a weekly, random check of locked files to ensure that client records are secured according to RAW and state regulations. Documentation of this corrective action plan will be reflected upon the QA/PI report. |
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 and the review of the Business Associate Agreement with Calloway Labs, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in six of eight client records reviewed. The facility also used consents to release information forms which contained "obtain from" language in six of eight client records reviewed.
Findings:
Eight client records were reviewed on March 10, 2009. The Business Associate Agreement with Calloway Labs was reviewed on March 4, 2009. The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to Calloway Labs in client records #1, 2, 3, 5 and 6. The Business Associate Agreement with Calloway Labs only referenced HIPAA regulations and did not comply with 42 CFR Part 2 Subpart B Subsection 2.12(c) (4). The consent to release information forms also contained "obtain from" language in client records #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The Executive Director of Rehab After Work will work with Calloway Labs Associate to update the Business Assocaite Agreement to include language pertaining to 42 CFR Part 2 Subpart B Subsection 2.12(c)(4). A copy of the new agreement will be kept on site at this location. Also, the consent to release information forms will be reprinted without the language "obtained from" on them. The Executive Director of Rehab After Work will monitor progress on both tasks until we are in full compliance with the standard. Effective immediately, the Site Director of Havertown has directed the staff to have all clients sign a consent to release form to Calloway Labs without "obtained from" printed on it. Also, a copy of the new Qualified Service Agreement will be kept at the Havertown location. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in six of eight client records reviewed.
Findings:
Eight client records were reviewed on March 10, 2009. A psychosocial evaluation was required in six client records.
The facility did not document a psychosocial evaluation to include the client ' s assets/strengths in client records # 1, 4 and 5.
The facility did not document a psychosocial evaluation to include the client ' s support systems in client records #2, 4, 5 and 6.
The facility did not document a psychosocial evaluation to include the client ' s coping mechanisms in client records # 2, 3, 4, 5 and 6.
The facility did not document a psychosocial evaluation to include the client ' s negative factors in client records # 1, 2, 4 and 6.
The facility did not document a psychosocial evaluation to include attitude toward treatment in client records #1, 4, 5 and 6.
The facility did not document a psychosocial evaluation to include counselor conclusions/impressions in client records # 1, 2, 4, 5 and 6.
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Plan of Correction
The Site Director of havertown & all counselors will attend a mandatory in-service training on the correct way to document "all" aspects of the psychosocial evaluation for every client. All staff will be required to sign off that they attended this training & that they understand the intent of the state regulation. The Site Director of Havertown will conduct monthly, random chart audits until the center is in full compliance & to ensure that this standard is being met. On 4/15/09 all staff attended the in-service training and signed off that they understood the intent of the state regulation. |
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 document an individual treatment and rehabilitation plan developed with the client in six of eight client records.
Findings:
Eight client records were reviewed on March 10, 2009. An individual treatment and rehabilitation plan developed with the client was required in six client records.
The facility did not document treatment plans developed with the client in records # 1, 2, 3, 4, 5 and 6.
The treatment plans were not signed by the client, and there was no documentation, in the client ' s progress notes, of the client participating in the development of the treatment plan
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Plan of Correction
The Site Director of Havertown will conduct an in-service training to inform staff that each client must sign off on the Master Treatment Plan. All Staff will sign off that they attended this training and that they understand this documentation represents the client's involvement in the development of the Master Treatment Plan. The Site Director of Havertown will conduct random, monthly chart audits to ensure that the standard in in full compliance.
On 4/15/09 all staff attended the in-service training and signed off that they understood that documentation represents the client's involvement in the deelopment of the Master treatment plan. |
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 the review of client records, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan on the treatment plan update in six of eight client records reviewed.
Findings:
Eight client records were reviewed on March 10, 2009. An assessment of the client's progress in relationship to the stated goals of the prior treatment plan was required in six client records. The facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan in client records #1, 2, 3, 4, 5 and 6.
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Plan of Correction
The site director of the Havertown location will conduct an inservice training on treatment plan updates, specifically "reflecting the client's progress on prior treatment plan goals". On 4/15/09 all staff attended the in-service training and signed off that they understood that on treatment plan updates client's progress toward prior goals must be reflected. The Site Director of Havertown will conduct random, monthly chart audits to ensure full compliance at the facility. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in three of eight client records.
Findings:
Eight client records were reviewed on March 10, 2009. Counseling services provided according to the individual treatment and rehabilitation plan were required in six client records.
The facility failed to document, either in the record of services or progress notes, that counseling services provided according to the individual treatment and rehabilitation plan in client records #1, 2 and 5.
Group sessions were prescribed three times per week in client record #1. The facility documented group sessions on 1/7, 1/9, 1/12, 1/14, 1/16, 1/19, 1/21, 1/23, 1/26, 1/3/0, 2/2, 2/4, 2/6, 2/9, 2/10, 2/11, 2/13 and 2/24/09.
Group sessions were prescribed two times a week in client record #2. The facility documented group sessions on 12/15, 2/18, 12/22, 12/29/08, 1/5, 1/7, 1/15, 1/27, 2/10, 2/17, and 2/24/09.
Individual sessions were prescribed one time per week in client record #5. The facility documented individual sessions on 12/11, 12/23/08, 1/12, 1/29, 2/12 and 3/5/09.
Group sessions were prescribed for three times per week in client record #5. The facility documented group sessions on 12/4/08, 1/8, 1/15, 1/22, 1/29, 2/5, 2/12, 2/19, 2/26 and 3/5/09.
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Plan of Correction
The Site Director of Havertown will conduct an inservice training on the documentation of individual/group progress notes "in accordance with stated frequency of services" noted in the individual's training plan. Also, use of progress notes/record of service notating an "Absence" will be reviewed. All staff will sign off that they attended this training & understand the intent of the regulation. The Site Director of Havertown will conduct random chart audits on a monthly basis until the standard is in full compliance. On 4/15/09 all staff atended an in-service training and signed off that they understood the intent of the above-stated regulation. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to document that counseling was provided to a client on a regular and scheduled basis in five of eight client records.
Findings:
Eight client records were reviewed on March 10, 2009. Counseling provided to a client on a regular and scheduled basis was required in six client records. The facility failed to document at least one individual session every 60 days for the completion of the comprehensive treatment plan and treatment plan update in client records #1, 2, 3, 4 and 6.
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Plan of Correction
The Site Director of Havertown will conduct and in-service training regarding documentation of at least one individual session every 60 days to review treatment plan updates on every client. All staff will sign off that they attended this training and understand the intent of this documentation. The Site Director will conduct random, monthly chart audits until the standard is in full compliance. On 4/15/09 all staff attended and in-service training and signed off that they understood that one individaul session every 60 days is required to review treatment plan updates for each client |
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 a review of client records, the facility failed to document a complete client record which included an aftercare plan in one of two client records where required.
Findings:
Eight client records were reviewed on March 10, 2009. An aftercare plan was required in two client records. The facility failed to document an aftercare plan in client record #8.
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Plan of Correction
The site director of Havertown will conduct and in-service training with the counselor of client record #8 to review documentation regarding aftercare planning. The counselor of client record #8 will sign off that they attended this supervision and will understand the intent of this documentation. The site director of Havertown will conduct monthly random chart checks until this standard is in compliance. On 4/15/09 The Site Director of Havertown met with the counselor of client #8 and other staff for an inservice-training. All signed off that they understood that documentation of aftercare planning is required |