INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 27, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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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
The facility failed to prepare alternate exit routes to be used during fire drills for all drills conducted during the review period of April 2018 and February 2019. Each fire drill conducted only utilized the rear exit.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff meeting was held on 3/25/19 to discuss Licensure issue 705.28. Supervisor discussed fire safety and fire drill protocol. Clinicians were made aware of future fire drill procedures and the importance of practicing fire drills using both front and rear entrances with monthly drills. Supervisor reviewed the building map to illustrate the front exit location, rear exit location and exit procedure. Supervisor will provide a fire drill map on the date of the fire drill illustrating both exit routs for clinicians. Maps of the building with fire escape routes will be displayed in each clinicians' office. Supervisor will have clinicians use both entrances for each fire drill and will document using both exits in the fire drill log monthly. |
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
The facility failed to assure that clients received the required counseling services according to the individual's comprehensive treatment plan in three of seven client records reviewed.Client #1 was admitted on October 24, 2018 and was still active at the time of the inspection. The comprehensive treatment plan, dated November 13, 2018, indicated the client was to receive one individual therapy session per week (four individual sessions per month). The chart's record of service and progress notes indicated that the client had received two sessions during the month of December 2018.Client #2 was admitted on November 12, 2018 and was still active at the time of the inspection. The comprehensive treatment plan, dated November 14, 2018, indicated the client was to receive four group therapy sessions per week (16 group sessions per month). The chart's record of service and progress notes indicated that the client had received only one group session during each of the following weeks: 1/21/19-1/27/19; 1/28/19-2/3/19; 2/4/19-2/10/19; 2/11/19-2/17/19; and 2/18/19-2/24/19.Client #4 was admitted on September 10, 2018 and was discharged on January 3, 2019. The comprehensive treatment plan, dated September 17, 2018, indicated the client was to receive four group therapy sessions per week (16 group sessions per month). The chart's record of service and progress notes indicated that the client had received two group sessions per week for 11/5/18-11/11/18 and 11/26/18-12/2/18; three group sessions per week for 10/29/18-11/4/18 and 11/19/18-11/25/18; and zero group sessions for the month of December 2018.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff meeting was held on 3/25/19 to discuss Licensure issue 709.92. Supervisor discussed the importance of offering counseling services that are consistent with recommendations outlined in the comprehensive treatment plan. Clinicians were instructed to ensure that clients who are admitted to group programs to be added to the group roster immediately to ensure accurate documentation of any missed sessions and that group sessions are being offered. Clinicians were reminded to accurately use Carelogic to document any sessions that were not attended with the correct reason for the absence. Clinicians were instructed to attempt to reschedule any missed or cancelled individual sessions within the same week to ensure services will be offered according to the comprehensive treatment plan. If a clients' recommendation for treatment is changed, clinicians were instructed to update the comprehensive treatment plan via a treatment plan review to reflect clients' current level of care to ensure sessions offered and recommendations are correlated. Supervisor will review monthly chart audits with clinicians in clinical supervision and will verify that clinicians are in compliance. |
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
The facility failed to provide follow-up information in the client's complete record in two of four applicable client records reviewed.Client #4 was admitted on September 10, 2018 and was discharged on January 3, 2019Client #6 was admitted on April 5, 2018 and was discharged on June 26 2018.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff meeting was held on 3/25/19 to discuss Licensure issue 709.93. Supervisor discussed the procedure for following up on recently discharged clients. Clinicians reviewed the OBH procedure for discharging clients from treatment. Clinicians reviewed all necessary paperwork including documenting 3 discharge calls for any client who leaves AMA, documenting all outreach attempts, completing a discharge letter, discharge summary depicting a clients' progress in treatment, discharge/transfer documentation and documenting a 7 day discharge outreach call following discharge from treatment. Supervisor will display all requirements for following up with a discharged client in the front office that all clinicians have access to and will make them aware of the resource. Supervisor will complete chart audits monthly and will discuss the requirements for follow up with clinicians during these chart audits, as well as during clinical supervision. |