INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19,2009 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 April 14, 2009.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records on March 3 and 19, 2009, the facility failed to document that the facility director meets the experiential qualifications for the position of facility director.Findings:Personnel records were reviewed on March 3, 2009. The facility director's resume was reviewed on March 19, 2009. The facility failed to document that employee #2 meets the experiential requirements of two years of experience in a human service agency which includes supervision of others and program planning.
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Plan of Correction
The Executive Director of Rehab After Work will ensure that the Site Director of the Lansdale location produce an updated resume that reflects thet she has 2 years of experience in a human service agency which includes supervision of others & program planning. This updated resume will be placed in the Site Director's personel file located at the Paoli office. The Executive Director will monitor until in compliance. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to document a minimum of 4 hours of tuberculosis/STD training in one of six personnel records. Findings:Nine personnel records were reviewed on March 19, 2009. Documentation of 4 hours of tuberculosis/STD training was required in six personnel records. The facility did not document 4 hours of Tuberculosis/STD training in personnel record # 5.
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Plan of Correction
The site director of Lansdale will meet with counselor #5 to ensure that she successfully completes a four hour Tuberculosis/STD training on 6/8/2009. Counselor #5 will provide verification that she attended this training and the site director will put the certificate in her personnel file. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on the review of the fire drill records and an interview with the facility director, the facility failed to document that the smoke detector was set off during each fire drill.Findings:The fire drill records were reviewed on March 19, 2009. An interview with the facility director regarding the fire drills was conducted on March 19, 2009. The facility failed to document that the smoke detector was set off during each fire drill. The facility director stated that the smoke detectors were not set off during the fire drills and that the facility was using an alternate means of announcing the fire drills. The facility director failed to provide documentation that the alternate means was approved by the Department of Health. The facility director also failed to document the inspection of the smoke detectors.
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Plan of Correction
The Site Director of the Lansdale Office will draft a letter and send to the Department of Health requesting that an alternate means of announcing fire drills can be used. This documention will be kept in the Site Director's log on location once it is received from the state. Also, the site director of Lansdale will provide documentation that the system is inspected during each monthly fire drill. This will also be kept in the Site Director's log located at the Lansdale office. Effective immediately, the site director of Lansdale will set off the fire alarm or smoke detector to announce all monthly fire drills and, as usual, will document results in the fire safe log. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative documents and an interview with the facility director, the facility failed to document a written agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage.Findings:The letters of agreement were reviewed on March 19, 2009. An interview with the facility director was conducted on March 19, 2009. The facility failed to document a written agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage.
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Plan of Correction
The Site Director of Lansdale will provide documention of a written agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage by 4/30/2009. A copy of the written agreement will be kept on site at the Lansdale location. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the physical plant inspection, the facility failed to secure client records within locked storage containers.Findings:The physical plant inspection was conducted on March 19, 2009 between 9:30 and 10:00 AM. The client records are stored in unlocked containers within a locked office. Counselors from a non-drug and alcohol program have access to this office both to retrieve mail and to access their program records.
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Plan of Correction
Site Director of Lansdale will ensure that all employees of Lansdale will secure client records within locked file cabinets at all times.
The Site Director of Landale will ensure that Life Counseling employees do not have access Rehab After Work records as they will be stored in locked, separtate cabinets. Effective immediately, RAW records will be stored within locked file cabinet.
Site Director of Lansdale will perform a weekly, random check of locked files to ensure that client records are secured according to RAW and state regulations. Documentation of this corrective action plan will be reflected upon the QA/PI report.
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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 and the review of the Business Associate Agreement with Calloway Labs, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in fourteen of seventeen client records reviewed. The facility also used consents to release information forms which contained "obtain from" language in seventeen of seventeen client records reviewed. Additionally, the facility released information without obtaining a consent in one client record.Findings:Seventeen client records were reviewed on March 19, 2009. An informed and voluntary consent was required in seventeen client records. The Business Associate Agreement with Calloway Labs was reviewed on March 6, 2009. The facility did not document a Qualified Service Organization Agreement with Calloway Labs. The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to Calloway Labs in client records #2, 3, 5, 6, 7, 8, 9, 10, 11 and 12. The Business Associate Agreement with Calloway Labs only referenced HIPAA regulations and did not comply with 42 CFR Part 2 Subpart B Subsection 2.12(c) (4). The consent to release information forms also contained "obtain from" language in client records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15,16 and 17. The facility failed to obtain a consent to release information in client record #15 for information released to the Criminal Justice Programs Manager at Bucks County Council on Alcohol and Drug Dependence, Inc.
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Plan of Correction
The Executive Director of Rehab After Work will work with Calloway Labs Associate to update the Business Assocaite Agreement to include language pertaining to 42 CFR Part 2 Subpart B Subsection 2.12(c)(4). A copy of the new agreement will be kept on site at the Lansdale location.
Effective immediately, the site director of Lansdale will instruct all staff to have each client sign a consent with Calloway Labs for the exchange of information until the agreement meets state standards.
Also, the consent to release information forms will be reprinted without the language "obtained from" on them. The Executive Director of Rehab After Work will monitor progress on both tasks until we are in full compliance with the standard. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document drug and alcohol histories in six of twelve client records. Findings:Seventeen client records were reviewed on March 19, 2009. Drug and alcohol histories were reviewed in twelve client records. The facility did not document drug and alcohol histories in client records # 1, 2, 3, 4, 8 and 16.Client records # 1, 4, 8 and 16 did not document a drug and alcohol history to include the length and patterns of drug use. Client record # 2 was admitted 11/10/08, but a drug and alcohol history was not documented at time of inspection.Client record # 3 was admitted 11/10/08, but a drug and alcohol history was not documented at time of inspection.
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Plan of Correction
On May 12, 2009, the Site Director of Lansdale and all counselors will attend a mandatory in-service training on the correct way to document drug and alcohol histories, ensuring that the site director and counselors of Lansdale are sure to learn how to document the length and patterns of drug use. Also on May 12, 2009, the Site Director will also meet with the counselors who performed the drug and alcohol history assessments of client records #1, 2, 3, 4, 8, and 16 on May 12, 2009 to illustrate how client record did not meet PA Department of Health Standard. The Site Director of Lansdale will conduct random, monthly chart audits until the standard is in full compliance and documented within the QA/PI report. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in ten of twelve client records. Findings:Seventeen client records were reviewed on March 19, 2009. Psychosocial evaluations were reviewed in twelve client records. The facility did not document a psychosocial evaluation in client records # 1, 2, 3, 4, 5, 7, 8, 9, 10 and 16.Client record # 2 was admitted 11/10/08, but a psychosocial evaluation was not documented at time of inspection.Client record # 3 was admitted 11/10/08, but a psychosocial evaluation was not documented at time of inspection.The facility did not document a psychosocial evaluation to include the client ' s assets/strengths that can contribute to the resolution of identified problems in client records # 1, 5, 7 and 16.The facility did not document a psychosocial evaluation to include the client ' s preferred coping mechanisms in client records # 1, 4, 5, 7, 8, 9 and 10.
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Plan of Correction
The Site Director of Lansdale & all counselors will attend a mandatory in-service training on 5/19/2009 on the correct way to document "all" aspects of the psychosocial evaluation for every client. All staff will be required to sign off that they attended this training & that they understand the intent of the state regulation. The Site Director of Lansdale will conduct monthly, random chart audits until the center is in full compliance & to ensure that this standard is being met.
On 5/19/2009, The Site Director of Lansdale will meet privately with the cousenlor of client records # 1, 5, 7 and 16 to provide extra training on the need/documentation of client's assets/strengths that can contribute to the resolution of client's identified problems. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan developed with the client in twelve of twelve client records.Findings:Seventeen client records were reviewed on March 19, 2009. Individual treatment plans were reviewed in twelve client records. The facility did not document an individual treatment plan developed with the client in records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15 and 16.The treatment plans were not signed by the clients, and there was no documentation, in the client ' s progress notes, to indicate the client ' s participation in the development of the treatment plans.
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Plan of Correction
On April 14th, 2009, the site director conducted an in-service training to inform staff that each client must either sign off on the Master and Updated Treatment Plan or that the client's progress notes reflect that the client partcipated in the development of their treatment plan in an individual session with their counselor. All Staff will sign off that they attended this training and that they understand this documentation represents the client's involvement in the development of the Master Treatment Plan. The Site Director of Lansdale will conduct random, monthly chart audits to ensure that the standard in in full compliance. |
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.
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Observations
Base on a review of client records, the facility failed to document a treatment plan update in nine of eleven client records.Findings:Seventeen client records were reviewed on March 19, 2009. A treatment plan update was required in eleven client records. The facility did not document a treatment plan update in client records # 1, 2, 3, 4, 5, 6, 7, 8 and 9.Treatment plan updates did not include an assessment of the client ' s progress in relationship to the stated goals of the treatment plan in client records # 1, 2, 3, 4, 5, 6, 7, 8 and 9.
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Plan of Correction
On April 14th, 2009, the site director of Lansdale conducted an in-service training to inform staff how to document a treatment plan update so that staff understands how to include an assessment of the client's progress in relationship to the stated goals of the treatment plan. The Site Director of Lansdale will conduct random, monthly chart audits to ensure that the standard in in full compliance.
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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
Based on a review of client records, the facility failed to document counseling services provided according to the individual treatment plan in five of twelve client records. Findings:Seventeen client records were reviewed on March 19, 2009. Documentation of counseling services provided according to an individual treatment plan was reviewed in twelve client records. The facility did not document counseling services according to the treatment plan in client record # 2, 3, 8, 15 and 16. Record # 2, treatment plan states Group sessions one time weekly, but group session progress notes were documented only two times in January and one time in February times in January.Record # 3, treatment plan states Individual sessions one time weekly, but Individual session progress notes were documented only two times in February.Record # 8, treatment plan states IOP sessions four times weekly, but IOP session progress notes were documented only twelve times in December and eleven times in January. Record # 15, treatment plan states IOP sessions four times weekly, but IOP session progress notes were documented only six times in June and four times in July. Record # 16, treatment plan states Individual sessions one times weekly, but individual session progress notes were documented only four times from 5/28/08 - 10/22/08. The facility did not document the reason(s) for undocumented counseling sessions.
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Plan of Correction
On 5/19/2009, the Site Director of Lansdale will meet the staff of client record #2, 3, 8, 15, and 16 on 5/19/2009 to provide training on the necessity for documentation of counseling services provided according to an individual treatment plan. The use of progress notes / record of service "notating an absence" will be reviewed. The counselor will sign off that they understand follow-up documentation and the intent of the policy/standard. The Site Director of Lansdale will conduct random, monthly chart audits until the counselors of client record #2, 3, 8, 15, and 16 are in full compliance with the standard. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed document counseling to clients on a regular and scheduled basis in seven of twelve client records. Findings:Seventeen client records were reviewed on March 19, 2009. Counseling on a regular and scheduled basis was reviewed in twelve client records. The facility did not document counseling on a regular and scheduled basis in client records # 1, 5, 7, 9, 11, 12 and 15.The facility did not document individual counseling sessions at least once every sixty days to discuss treatment plan updates with clients in records # 1, 5, 7, 9, 11, 12 and 15.
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Plan of Correction
On 4/14/2009, the Site Director of Lansdale conducted an in-service training to inform staff that counseling shall be provided to a client on a regular and scheduled basis. The Site Director of Lansdale will inform the staff that there must be documentation that the staff provide counseling / meet with clients at least once every sixty days to discuss treatment plan updates. The Site Director of Lansdale will conduct random, monthly chart audits to ensure that the standard is in full compliance. |
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, the facility failed to document an aftercare plan in one of two client records. Findings:Seventeen client records were reviewed on March 19, 2009. An aftercare plans were required in two client records. The facility did not document an aftercare plan in client record # 14. Record # 14 was discharged 9/30/08, but and after care plan was not documented at time of inspection.
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Plan of Correction
The Site Director of Lansdale will meet with counselor of client record #14 on 4/28/2009 to review the necessity of completing the client record with the inclusion of an Aftercare Plan when applicable. The counselor of client record #14 will sign off that they attended this supervision and will understand the intent of this documentation. The site director of Lansdale will conduct monthly random chart checks until this standard is 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
Based on a review of client records, the facility failed to document follow-up information in three of seven client records.Seventeen client records were reviewed on March 19, 2009. Follow-up information was required in seven client records. The facility did not document follow-up information in client records # 10, 13, 14 and 16. Record # 10 was discharged 1/21/09, but follow-up information not documented at time of inspection.Record # 13 was discharged 11/5/08, but follow-up information not documented at time of inspection.Record # 14 was discharged 9/30/08, but follow-up information not documented at time of inspection.Record # 16 was discharged 10/22/08, but follow-up information not documented at time of inspection.
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Plan of Correction
On 5/26/2009, The Site Director of Lansdale will conduct an in-service training to inform staff of how to document follow-up information after client has been discharged. The staff will sign off that they understand follow0up documentation and the intent of the policy/standard. The site director of Lansdale will conduct random, monthly chart audits to ensure staff is in full compliance with standard/policy. |