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 14, 2011 licensure renewal inspection.
The follow-up inspection was conducted on August 15, 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 responses from the state submitted on 9/16/11 regarding an exception for the Clinical Supervisor staffing requirement. If execption is not granted, the Executive Director will need to re-structure current clinical supervision procedures by adding/benefit eligible full-time clinical supervisors as per state regulations. The Executive director will need to obtain Governing Body approval to re-organize salary structurs and potentially downsize by closing smaller offices |
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 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 accordancwe with state regulation |
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, the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in client records that complied with 4 Pa. Code subpart (b).
The findings include:
On August 15, 2011 six client records were reviewed to ensure that the facility was obtaining informed and voluntary consents for the disclosure of information contained in the clients' record that complied with 4 Pa. Code three of six client records reviewed, specifically client records # 2, 3, and 4 the facility failed to limit the information being released to a third party payer to the following information as permitted under 4 Pa. Code subpart (b):
1. Whether the client is or is not in treatment.
2. Client's prognosis.
3. The nature of the project.
4. A brief description of the client's progress.
5. A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
It should be noted that the facility's consent to release information forms titled, "Authorization To Release Information Form", had items 1-5 above listed with checkboxes to limit the information to the five permissible areas; however, the facility checked the box labeled "Other" and wrote in "Chart Contents".
Client # 2 was admitted to the program on 5/9/11 and discharged on 6/13/11.
On 5/9/11 client # 2 signed and dated an "Authorization To Release Information Form" to a "Managed Care/Insurance Company" which documents allowing the release of "chart contents."
Client # 3 was admitted to the program on 4/25/11 and discharged on 7/25/11.
On 4/25/11 client # 3 signed and dated an "Authorization To Release Information Form" to a "Managed Care/Insurance Company" which documents allowing the release of "chart contents."
Client # 4 was admitted to the program on 6/6/11.
On 6/6/11 client # 4 signed and dated an "Authorization To Release Information Form" to a "Managed Care/Insurance Company" which documents allowing the release of "chart contents."
The release of "chart contents" fails to ensure that specific information is disclosed; thus the release exceeds the limits imposed by 42 C.F.R. and 28 Pa. Code 709.28.
In addition, allowing the release of "chart contents" constitutes a general consent to release information as prohibited at 42 C.F.R. Part 2, Subpart C, A general consent does not rise to the level of an informed and voluntary consent.
The Facility Director confirmed the findings.
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Plan of Correction
The Site Director of Havertown will conduct an in-service training to inform all staff that all releases in client records must limit the information to the five permissable areas. The "Managed Care/Insurance Company" or any other release will NOT have the phrase "chart contents" or "other" on any release form
On 9-14-11 the Site Director of the Havertown Office conducted a one-hour training regarding the confidentity limitations (five areas of disclosure). The Havertown Site Director will continue to conduct monthly chart check to ensure that this deficiency does not recur |
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
This was still out of compliance at the time of the follow-up inspection conducted on August 15, 2011.
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Plan of Correction
On 3-12-11 The Site Director of the Havertown Location of Rehab After Work conducted a one-hour training for all staff regarding the requiremant of having a detailed aftercare plan for each patient completing treatment at Rehab Aftr Work. It is the responsibility of the counselor to meet each patient and develop a detailed coninuing care plan within one month of discharge. All Staff signed off on the 3-12-11 training. May it be noted that no closed charts were reviewed during the follow-up inspection 0f 8-15-11. The Havertown Site Director will conduct monthly chart checks to ensure that detailed aftercare plans are in all closed charts |
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 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.
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.
This area of noncompliance was also identified during the February 11, 2011 licensing inspection. The plan of correction was submitted on 4/4/11 and approved on 4/6/11.
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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 Govening 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
The Exective Director of Rehab After Work is currently awaiting respones from the state submitted on 9/16/11 regarding an execption for the Clinical Supervior staffing requirement. If execption is not granted, the Executive Director will need to restructiure current clinical supervision procedures by adding salaried/benefit eligible full-time clincial supervisors as per state regulations. The Executive Director will need to obtain Governing Body approval to re-organize salary structiures and potentially downsize by closing offices |