INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on February 14, 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 1 full time clinical supervisor for each 8 FTE |
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 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.
An interview with the Facility Director on February 11, 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 3, 2010 for failing to document an annual financial audit.
In response to the citation issued on March 3, 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 the last fiscal year and each year to follow. The Project Director will assure that these are done on anannual 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 one of four records reviewed.
The findings include:
On February 11, 2011 one personnel record was reviewed for fingerprint based national criminal history record checks. The facility did not document a fingerprint based national criminal history record check in personnel records # 3.
Employee # 3 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.
Employee # 3 was hired on December 13, 2010, but the fingerprint based national criminal history record check was not documented at the time of inspection on February 11, 2011.
An interview with the facility director on February 14, 2011 confirmed that personnel record #3 did not contain a fingerprint based national criminal history record check
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Plan of Correction
The Human Resource Director of Rehab After Work will ensure that all current and future hires will have an FBI backgorund check. A copy will be placed in their HR file and all future hires will not be allowed to carry a clinical caseload until the FBI check has been completed. The Site Director of Havertown has verified that a criminal records check is in the personnel file of counselor #3 |
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, a review of the facilities policy and procedures manual, and an interview with the facility director, the facility failed to document a complete client record which included an aftercare plan.
The findings include:
The facilities policy titled "Continuing Care Plan" states:
The final phase of treatment is aftercare planning. RAW policy requires that patients develop an effective detailed plan for maintenance of sobriety after completing the program. The primary counselor is responsible for meeting with the patient to develop a detailed continuing care plan for the patient to follow after they leave formal treatment. The continuing care plan is completed within one month of the scheduled discharge date in the context of ongoing individual counseling sessions. The continuing care plan is completed and signed by the patient and counselor before anticipated discharge.
Five discharged clients' records were reviewed on February 14, 2011.
One discharged client record was required to have documentation of an aftercare plan.
The facility failed to document a complete client record including an aftercare plan in accordance with facility policy in client record # 5.
Client # 5 was admitted to the program on 5/12/10 and discharged on 10/25/10.
Client # 5 completed treatment per progress note, discharge summary, and conversation with the facility director and the primary counselor.
At the time of review on 2/14/11 the facility failed to document an aftercare plan.
The facility director confirmed that client # 5's record did not have documentation of an aftercare plan.
This is a repeat deficiency from the 3/22/10, 3/10/09 and was previously cited during the 7/27/05, 9/3/04, and the 6/21/02 inspections.
The Plans of correction submitted for the 2009 and 2010 inspections are indicated below::
2010
The Site Director of Havertown will conduct an in-service training to inform all staff that it is required that all client records must have aftercare plans completed within one month of discharge. Primary counselors are to meet with the client to develop a detailed Continuing Care Plan for the client to follow after they leave formal treatment. The Site Director of Havertown will conduct monthly chart audits to ensure that this standard is in full compliance
2009
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
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Plan of Correction
The Site Director of Havertown will conduct an in-service training to inform all staff that it is a requirement that all client records must have aftercare plans within one month of discharge. Counselors are to meet with clients to develop a detailed Continuing Care Plan for the client to follow after they leave formal treatment. The Site Director will conduct monthly chart audits to ensure this standard is in full 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
Based on a review of client records, a review of the facilities policy and procedures manual, and an interview with the facility director, the facility failed to document a complete client record which included follow-up information.
The findings include:
The facilities policy titled " Follow-Up Information" states:
When a patient has been discharged and referred to an outside resource, the counselor or a designee of the site director, with the written consent of the client and within one week from the day the referral is completed, attempts to determine from the resource and/or client the disposition of the referral. The counselor and/or designee of the site director then will document the attempt in at least one of the following areas located on the chart:
1. At bottom left section of the Record of Service-under additional notes section;
2. On right side of the Record of Service- under notes column;
3. Or documented in the Discharge Summary section of the chart.
Five discharged client records were reviewed on February 14, 2011.
Two discharged client records requiring documentation of follow-up were reviewed.
The facility failed to document a complete client record including follow-up information in client record # 5 and 8.
Client # 5 was admitted to the program on 5/12/10 and discharged on 10/25/10.
Follow-up information is to be documented within one week according to policy, follow-up was not documented at the time of review on 2/14/11.
Client # 8 was admitted to the program on 8/19/10 and discharged on 10/18/10.
Follow-up information is to be documented within one week according to policy, follow-up was not documented at the time of reviewed on 2/14/11.
The facility director confirmed that follow-up information was not documented for client # 5 and 8.
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Plan of Correction
The Site Director of Havertown will conduct an in-service training to inform all staff that after a client has been discharged from treatment a follow-up call is required within one week of that referral to an outside resource. The Counselor will document the attempt on the Record of Service or in the Discharge Summary section of the chart. The Site Director will conduct monthly chart audits to ensure that this standard is in full compliance |