INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21, 2012 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:
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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 AfterWork will change the policy and procedures section in our manual(#66006) to reflect that"information specifically released to employers will be limited to whether a client has or is recieving 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 our Phenoxville location. This policy addendum will be reviewd for all staff as part of the training. Site directors will perform random, monthlychart audits to ensure that this policy change is being reflected by all clinicians. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record log, the facility failed to prepare alternate exit routes to be used during fire drillsThe findings include: The fire drill record log was reviewed on March 21, 2012. The log was reviewed from the time period covering March 2011 to February 2012. The fire drill log documented the same exit was used during fire drills for eleven out of twelve fire drills. For the drills conducted on 4/20/11, 5/9/11, 6/21/11, 7/14/11, 8/9/11, 9/14/11, 10/13/11, 11/15/11, 12/8/11, 1/10/12, and 2/21/12 all indicate Route Used: " front & back "The findings were confirmed with the site director during the exit interview.
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Plan of Correction
The site director of Lansdale will ensure that alternate exit startagies are utilized for monthly fire drill exercises beginning 4/21/12 so that staff and clients are aware of and use these alternate exits. This will be evidenced by documentation included in the monthy fire drill log. |
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 21, 2012 three client records were reviewed for documentation of a follow-up. One out of three client records lacked documentation of a follow-up, specifically client record # 5. Client #5 was admitted on October 26, 2011 and discharged on January 23, 2012. A follow-up was due to be documented by January 30, 2012, as of the date of the inspection, there was no follow-up documented for client # 5.
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Plan of Correction
The site director will have an inspection review training scheduled for 5/8/12 reviewing the procedure related to follow up calls regardless the reason for discharge must be within 7 days. The site director will randomly audit charts quarterly to ensure this procedure is being followed by clinicians. |
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" (SRFSR) for all of the facilities 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:The SRFSR for the fourteen facilities that make up the project list a total of 57 counselors (some full time and some part time) and fourteen part-time clinical supervisors. The total of the hours per week provided to the project by counselors equates to 46 FTE counselor positions within the project.The SRFSR for the fourteen facilities within the project revealed that no employees were listed as a full-time clinical supervisor. The SRFSR listed each of the fourteen part-time clinical supervisors as facility directors; therefore they are unable to provide full-time clinical supervision. In addition nine of those part-time clinical supervisors carried a caseload above five clients, which further prevents their ability to provide full-time clinical supervision to their staff. A full-time equivalency of 46 counselors would require a minimum of 5 full-time clinical supervisors and one part-time clinical supervisor within the project.This finding was confirmed with the project director during the administrative review.
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Plan of Correction
The facility is requesting an exception to this standard. If an exception is not granted, the project will ensure that there is one full time clinical supervisor for every 8 FTEs. Should the exception not be granted, the Project Director will monitor the staff schedules to ensure compliance with the licensing standard 704.6(a) as written. |