INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on
February 11 -12, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, Inc - Vandergrift 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 17, 2008.
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Plan of Correction
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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(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 clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of the personnel records on February 11, 2008, the facility failed to meet the experiential qualifications for the position of clinical supervisor. Refer to record #2.
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Plan of Correction
Due to the clinical supervisor lacking experiential qualifications the clinical supervisor who was just promoted in January will now be the cheif counselor until he is able to meet the experiential qualifications required in this regulation. In the future greater care will be taken in reviewing the regulatory qualifications. The responsibility falls on the facility director to ensure that this regulation is consistently met. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill record on February 11, 2008, the facility failed to provide documentation that the fire alarm/smoke detector was operative. This was cited at the last licensing survey, and although the fire drill record form was updated to include this information, the new form has not been used for documenting the drills.
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Plan of Correction
The front desk administrator under the supervision of the facility director is responsible for ensuring that this regulation is met. The front desk will be instructed to begin utilization of the form created following the last inspection which includes documentation that the fire/smoke detector is operative. To ensure continued compliance the facility director will review fire drill documentation quarterly and ensure that the front desk administrator is in fact documenting the operation of the fire/smoke detector. |
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 client record reviews on February 11 & 12, 2008, the facility failed to provide signed consent to release information forms for funding sources. This was noted in five of ten client records reviewed. Refer to record # 3, 5, 6, 7, & 9. Record #4 included a release of information that was missing the agency to whom the information would be disclosed.
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Plan of Correction
The facility director is responsible to ensure that all release are completed and filed correctly. To ensure that the releases of information for funding sources are signed and in the clinical record the facility director will update the intake files to include the releases for funding so that they may be completed during the intake process thereby removing the responsiblity to ensure that it is completed by the assigned counselor. The staff will then be informed that this release is to be completed at intake for any individuals who are recieving public funding. In three months a random chart audit will be completed to ensure that these releases are being completed and filed correctly and that this regulation is met consistently. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records on February 11 & 12, 2008, the facility failed to provide complete goals and objectives on the treatment plans. Interventions are not specific as to how the goals will be met. Issues and problems identified in the history, psychosocial evaluation, and 30 day assessment are not reflected in the treatment planning. In addition, goals and objectives should reflect treatment issues and not only focus on case management.
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Plan of Correction
The facility director is responsible to ensure that this standard is met consistently. In order to facilitate this a staff training will be scheduled to educate and discuss required improvements to meet this regulation. Following the training all treatment plans will be reviewed by the facility director. Ongoing training will continue until the regulation is being met consistently. |