INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21, 2016 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.
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training.
The findings include:
Three personnel records were reviewed on January 21, 2016. The facility's training year was from January 1, 2015 through December 31, 2015. The facility failed to ensure employee # 4 completed at least 25 clock hours of annual training.
Employee # 4 was hired as a counselor November 3, 2014, and was required to complete 25 hours of annual training. Employee # 4's training file did not include training hours for 2015.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During first staff meeting in March 2016: Site Director will conduct inservice training with clinical staff to review DDAP training requirement of 25 Hours per calendar year for each clinician.
Site Director will audit each counselor's training hours in staff development log quarterly to ensure that each staff is on target for fulfillment of annual staff development quota of 25 hours annually as per DDAP requirement. Such audit will be documented in their individual supervision logs and discussed with clinician quarterly as well.
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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, the project failed to document informed and voluntary consent to release forms that complied with Pa Code 255.5.
The findings include:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed
Ten client records were reviewed on January 21, 2016. The project failed to document informed and voluntary consent to release forms in all client records reviewed, # 1, 2, 3, 4, 5, 6, 7 and 8.
1. The project has a "Managed Care/Insurance Company Authorization to Release Information Form" that all clients sign and agree to consent to release. The "Managed Care/Insurance Company Authorization to Release Information Form" is a project wide template form. The other box is checked off on this template form with the pretext "level of care evaluations, Authorizations, Status reports and Recommendations, Chart contents."
The release or documentation of the release of the client's "level of care evaluations and chart contents" does not comply with the stipulations of 255.5.
2. In addition, the project has a form titled "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company - The Light Program/Life Counseling Services/Rehab After Work," that was revised 10/15.
The form documents, "My signature below indicates my permission for The Light Program/Life Counseling Services/Rehab After Work to bill my insurance for payment. I give my permission to disclose information such as my diagnosis, my medication and dates I will be attending, as well as other pertinent information in order for my insurance company to grant authorization of my attendance."
The release or documentation of the release of the client's "medication and dates I will be attending as well as other pertinent information in order for my insurance company to grant authorization of my attendance" does not comply and exceeds the limitations imposed at 255.5.
3. Lastly, client # 2 was admitted to the facility on October 23, 2015. On October 14, 2015, client # 2 signed a blank consent to release form that did not include the specific information to be disclosed or the purpose of the disclosure. The consent to release initially documented the release to probation, but probation was crossed out and case worker added. The licensing specialist inquired about the consent to release form, but no further information was provided.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
709.28 (c) Confidentiality
Site Director will conduct training on Confidentiality with staff members during weekly staff meeting on February 17, 2016. During this meeting, Site Director will review regulations and policies regarding client confidentiality, 4Pa. Code 255.5. Site Director will perform quarterly audits of 12 charts minimum in order to monitor compliance with confidentiality regulations. Site director will perform these audits to ensure that the appropriate measures and documentation of confidentiality is being utilized in all consent forms on Rehab After Work paperwork, specifically stating the purpose for the release at hand. The current managed care consent form/release information to insurance company form will be edited to utilize proper terminology and stay within the 4Pa. Code 255.5 regulation of confidentiality. The new consent form was sent out to all Rehab After Work clinicians on January 18th, 2016 and will be utilized from that date moving forward, replacing the previous managed care consent form. Current clients are to be given the new managed care release form as well as a copy for their own records.
The Financial Responsibility and Agreement form will be revised as of March 5, 2016 and provided to all clients as well, stating that no information of client, beyond the five items listed in Pa. Code 255.5, shall be disclosed.
A training will be provided by the Site Director on March 2, 2016 to review the thorough completion of consent forms. It will be emphasized that every consent form much indicate the specific information to be released as well as the purpose of releasing the information. This will be monitored in conjunction with the quarterly audits to insure both compliance with confidentially across all releases.
With regards to client #2, client was successfully discharged on December 24, 2015 and is no longer an active client. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record which included an aftercare plan.
The findings include:
Four discharge client records were reviewed on January 21, 2016. The facility failed to document a complete client record which included an aftercare plan in two successfully discharge client records reviewed, client record # 6 and 7.
Client # 6 was admitted to the facility on November 17, 2015 and successfully completed the program on January 18, 2016. The facility failed to document a complete client record which included an aftercare plan for client # 6.
Client # 7 was admitted to the facility on April 6, 2015 and successfully completed the program on May 28, 2015. The facility failed to document a complete client record which included an aftercare plan for client # 7.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Site director will review the aftercare plan documentation and policy and procedures for such documentation to be compliant with DDAP in group supervision meeting on February 24, 2016, explaining to staff that all successfully discharged clients need to review their aftercare plans with their clinician during the last session. If the client is willing to adhere and agree to the aftercare plan then he/she will sign the document as well.
The two clients (#6 and #7) that did not have an aftercare plan will be sent aftercare plans for their review and signature if they are willing to adhere to the plan stated via mail and request that it be sent back to the facility for filing in their chart.
Discharged client charts will be audited every other month to ensure the appropriate documentation is being utilized. Audits will be documented in the staff development log. |