INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 30, 2017 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 to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
|
Plan of Correction
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of staff records conducted on March 6-7, 2017, the facility failed to ensure that a staff member received the required training hours.Employee #5 was hired as a counselor in 7/4/06 but received only 24 hours of training during the 1/1/16 thru 12/31/16 training year.This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Clinical Supervisor will review training hour requirements with staff member #5. During individual supervision, Clinical Supervisor will check status of training hours completed. Staff member #5 will have 25 training hours completed by December 31, 2017. Clinical supervisor will check status of training hours completed by clinicians as part of individual supervision completed every other week. In addition to the HR department, clinical supervisor will make sure that clinicians are aware that training hours cannot be prorated in the event of a clinician being on leave during the calendar year. |
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.
|
Observations
Seven client records were reviewed on March 30, 2017. The project has a form titled "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company " which was found in client records #2, 3, 4, 5, 6 & 7.This form authorizes the release of the client's medication, and dates of attendance as well as "other pertinent information in order for my insurance company to grant authorization of my attendance" which exceeds the limitations imposed at 255.5.Client #2 was admitted on 9/8/16 and was an active client at the time of the licensing inspection. The Financial Responsibility Agreement release was signed and dated on 9/8/16. Client #3 was admitted on 5/2/16 and was an active client at the time of the licensing inspection. The Financial Responsibility Agreement release was signed and dated on 5/2/16. Client #4 was admitted on 9/2/16 and was discharged on 11/3/16. The Financial Responsibility Agreement release was signed and dated on 9/2/16. Client #5 was admitted on 6/2/16 and was discharged on 8/2/16. The Financial Responsibility Agreement release was signed and dated on 6/2/16. Client #6 was admitted on 7/7/16 and was discharged on 9/14/16. The Financial Responsibility Agreement release was signed and dated on 7/7/16. Client #7 was admitted on 7/26/16 and was discharged on 12/1/16. The Financial Responsibility Agreement release was signed and dated on 7/26/16.This is a repeat citation.This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
A staff meeting was held on 4/3/17; training on 255.5 was conducted and a copy of the correct form was given to all of the clinicians. The non-compliant form was removed from the document server on the printer as well. Clinicians will review all current active charts and remove the non-compliant form and replace it with the correct form by 4/14/17. Clinical supervisor will remind staff 1x monthly to utilize up to date form provided on google sites and supervisor will conduct monthly chart audits to ensure 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.
|
Observations
Seven client records were reviewed on March 30, 2017. The facility failed to update the treatment plan every 60 days in two of five applicable client records.Client #2 was admitted on 9/8/16 and was an active client at the time of the licensing inspection. A treatment plan update was created on 11/10/16; a treatment plan update was due by 1/10/17 but was not documented until 1/12/17.Client #3 was admitted on 5/2/16 and was an active client at the time of the licensing inspection. A treatment plan update was created on 6/30/16; a treatment plan update was due by 8/30/16 but was not documented until 9/1/16. Additionally, a treatment plan update was created on 10/31/16; a treatment plan update was due by 12/31/16 but was not documented until 1/2/17. A subsequent treatment plan update was due by 3/2/17 but was not documented until 3/6/17.This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
A staff meeting was held on 4/3/2017; reviewed requirements for doing treatment plans and treatment plan updates. Went over how to calculate the 60 days so that it is in compliance and discussed what to do if a client is absent on the day that the update is due. Clinical supervisor will review treatment plans and updates with clinicians during individual supervision and conduct monthly chart audits to ensure that treatment plan updates are being completed with the 60 day time frame. |