INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Lower Merion Counseling Services 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(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment.
Employee # 3 was hired at the facility on May 26, 2009 and was promoted to the position of clinical supervisor on September 7, 2015. Employee #3 was required to participate in documented monthly meetings with their supervisor from October 2015 - March 2015. The facility failed to document monthly supervision for November 2015 and December 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervision notes were in place before and after missing note. Supervisions are scheduled and attended on a monthly basis. Going forward, both Director and Clinical Supervisor will ensure monthly supervisions are scheduled and confirmed as a part of the monthly supervision conversation. |
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.
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Observations
The facility failed to obtain an informed and voluntary consent to release in one of seven client records reviewed during the course of the annual licensing inspection on July 28, 2016.
Client #6 was admitted on February 4, 2016 and was discharged on April 23, 2016. On a consent to release form to the DUI Administration, the facility failed to obtain the clients signature and date. In addition, a letter dated 4/23/2016 was sent to the DUI Administration containing client identifying information with out a proper consent to release from the client. In addition, a fax was sent on 2/11/2016 to a case worker containing confidential information however a consent to release form was not obtained for this individual until 2/25/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to client #6 being discharged at the time of review, nothing can be done to correct this for now.
Going forward, a review of all DDAP individuals seen at LMCS will be conducted by the QA and Clinical Supervisor on a monthly basis and double-spot checked on a quarterly basis to ensure valid consents are in place, signed, dated and reviewed by clinicians, individual seeking services, et al.
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