INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 2, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab Management Inc./Rehab After Work 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.
|
Plan of Correction
|
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.
|
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.
|
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.
|
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 10, 2011 the Project ' s administrative records were reviewed for a financial audit following the end of their fiscal year. The Project ' s 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 March 2, 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 22, 2010 for failing to document an independent financial audit.
In response to the citation issued on March 22, 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.
|
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 last fiscal year and each fiscal year to follow. The Project Director will assure that these are done on an annual basis. |
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:
|
Observations
Based on the review of client records and an interview with the facility director the facility failed to document an individual treatment plan in five of seven records.
The findings include:
On March 2, 2011 seven client records were reviewed for individual treatment plans. The facility did not document an individual treatment plan based on the individual's problem and situation, as per facility policy, in client records # 1, 2, 3, 4 and 6.
The facility ' s policy titled " Treatment and Rehabilitation Plan " states:
" The Comprehensive Treatment Plan must include a minimum of three key problem areas with defined goals. For each treatment goal, the plan must specify at least three objectives (that is, readily observable or measurable ways to reach the goal) and the time frame for achieving the goal. In most cases, two key goals are abstinence and sober supports. Other goals depend on the individual ' s problem and situation, and may include treatment for anxiety, depression, marital stress, employment problems, parenting problems and so forth. The goals are developed in collaboration between patient and counselor and signed by the counselor. "
The comprehensive treatment plans in client records #1, dated 10/15/10, client record #2 dated 10/25/10, and client record #6 dated 9/2/10 all contained goals and objectives that were nearly identical each other.
The comprehensive treatment plans in client records #3, dated 11/2/10 and client record #4 dated 10/13/10 contained goals and objectives that were nearly identical each other.
An interview with the facility director on March 2, 2011 confirmed that the goals and objectives in the identified client records were nearly identical.
This is a repeat citation. The facility was cited on March 22, 2010 for failing to document individual treatment plans.
In response to the citation issued on March 22, 2010, the facility provided the following plan of correction:
The site director of center city will have an inservice training with all the clinical staff on Individual Treatment Plans by 4/28/10. All staff will sign off that they attended the training and understand the intent of this documentation. The site director will perform random monthly chart audits until the center is in full compliance
|
Plan of Correction
Training on this issue wil begin immediately & be ongoing. The Executive Director will have all counselors of the center city office attend a mandated training on development of individual treatment plans. All counselors will sign off that they understand the intent of the standard and will comply with all aspects of treatment planning. The Site Director will complete bi-monthly chart audits until the center is in full compliance. A follow-up seminar will be provided by 5/30/2011 to review all aspects again on treatment planning & discuss results of ongoing random chart audits. |
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.
|
Observations
Based on the review of client records and in interview with the facility director, the facility failed to document a treatment plan update in five of seven client records.
The findings include:
On March 2, 2011 seven client records were reviewed for documentation of treatment plan updates. The facility did not document a treatment plan update, as per facility policy, in client records # 1, 2, 4, 5 and 6.
The facility's policy titled " Treatment Plan Review and Update " states:
1.The Comprehensive Treatment Plan shall be reviewed and updated at least every 60 days.
2.The Comprehensive Treatment Plan review and update should include an assessment of the patient's progress in relationship to the stated goals of the plan. "
In client record #1, the treatment plan updates documented on 10/28/10, 12/22/10 and 2/22/11 did not include an assessment of the patient's progress.
In client record #2, the treatment plan updates documented on 12/25/10 and 1/17/10, did not include an assessment of the patient's progress.
In client record #4, the treatment plan updates documented on 11/1/10 and 12/31/10 did not include an assessment of the patient's progress.
In client record #5, the treatment plan update documented on 10/14/10 did not include an assessment of the patient's progress.
In client record #6, the treatment plan updates documented on 9/28/10 and 11/9/10 did not include an assessment of the patient's progress.
Additionally, the treatment plan updates in client record #1 dated 10/28/10 and client record # 6 dated 9/28/10 were nearly identical.
An interview with the facility director on March 2, 2011 confirmed that the treatment plan updates in the identified client records did not include and assessment of the patient's progress.
|
Plan of Correction
Training on this issue will begin immediatley and be ongoing. The Executive Director will complete a training seminar on treatment plan updates by 3/31/2011. All counselors at the center city location will attend and signoff that they understand the intent of the standard. The site director of center city will complete random, monthly chart audits until the center is in full compliance. |