INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24, 2015 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on 1/20/2015, the facility failed to ensure that staff caseloads remained at or under 35:1.The findings include: The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on 2/24/2015. Based on the total number of hours per week that the employee # 3 devoted to clients and the standard work week of 35 hours, employee # 3 exceeded the allowable maximum 35:1 caseload.The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the standard work week of 35 hours. The number of hours per week devoted by employee # 3 to drug and alcohol client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 5 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that employee # 3 had 6 active clients on 1/20/2015.Employee # 3 (5/35 = .1428 FTE 6 clients/.1428 FTE = 42:1 caseload)These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Site Director will review current roster of RAW clinicians at the site and number of active clients per clinician to insure compliance with required ratio (35:1)
2. Where ratio is out of compliance with regulations, Site Director will make the appropriate adjustment to the clinician's caseload.
3. Clinical Supervisor will review number of active clients for each clinician in individual supervision sessions held every other week and will make adjustments to caseload where necessary. |
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 facility failed to obtain an informed and voluntary consent that includes all of the content required by regulation in one of ten client records reviewed.The findings include:Ten client records requiring informed and voluntary consent to release information forms were reviewed on 2/24/2015. The facility failed to document all of the content required by regulation on an informed and voluntary consent to release information form in client record # 4. Client # 4 was admitted to treatment on 7/16/2014. Client # 4's informed and voluntary consent to release information to the client's funding source dated 7/16/2014 did not specify the name of the organization to whom the disclosure was authorized. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Site Director will conduct a review for all site clinicians of the regulations pertaining to informed and voluntary consent of clients. Included in the review will be training on proper completion of release of information forms, including but not limited to identification of party to whom information is to be released.
2. Site Director will conduct random review of 10 charts per month to ensure compliance with the regulations pertaining to release of information forms. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document, specify the reason for termination, on the written notification of the facility ' s decision to involuntarily terminate a client's treatment in two of two client records.The findings include:Two client records were reviewed for documentation of a termination letter on 2/24/2015. The facility failed to include the reason for involuntary termination in the written termination notices that were sent to clients # 4 and 6. Client # 4 was admitted to the program on 7/16/2014 and was involuntarily terminated from the program on 10/16/2014. The termination letter dated 10/18/2014 did not specify the reason for termination. Client # 6 was admitted to the program on 9/19/2014 and was involuntarily terminated from the program on 12/3/2014. The termination letter dated 12/3/2014 did not specify the reason for termination. These findings were reviewed with facility staff during the licensing process.This is a repeat citation. The facility was previously cited for non-compliance with this standard during the 2/7/2014 inspection.
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Plan of Correction
1. Site Director will conduct a training for all site clinicians on the process for involuntary termination of client services. Included in the training will be a review of the documentation necessary for involuntary termination. In particular, clinicians will receive training in the composition of an appropriate letter of termination that includes specific reasons fo involuntary termination.
2. Site Director will conduct a random monthly review of 10 charts to insure compliance with the regulation. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to maintain documentation that individual treatment and rehabilitation plans were developed with the client in three of ten client records reviewed. The findings include:Ten client records requiring documentation that individual treatment and rehabilitation plans were developed with the client were reviewed on 2/24/2015. There was no documentation that individual treatment plans were developed with the client in client records # 1, 2 and 3.Client # 1 was admitted to treatment on 10/29/2014. There was no documentation that the client's individual treatment and rehabilitation plan dated 12/29/2014 was completed with the client. Client # 2 was admitted to treatment on 7/15/2014. There was no documentation that the client's individual treatment and rehabilitation plans dated 11/20/2014 and 1/15/2015 were completed with the client. Client # 3 was admitted to treatment on 11/12/2014. There was no documentation that the client's individual treatment and rehabilitation plan dated 11/17/2014 was completed with the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Site Director will conduct a training of all clinicians on the development of treatment and rehabilitation plans. Specific focus will be given to requrement that clients must be involved in the development of these plans. Furthermore, the training will emphasize the need to document in the chart the client's involvement in the developments of treatment and rehabilitation plans.
2. Site Director will conduct a monthly random review of ten charts to insure that treatment and rehabilitation plans are in compliance with state regulations. |
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 the review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in six of ten client records reviewed. The findings include:Ten client records were reviewed for counseling services on 2/24/2015. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records # 1, 2, 3, 4, 5 and 10.Client record # 1 contained a treatment plan dated 11/10/2014 that identified the counseling services to be provided as group therapy sessions 4 time per week. There were no group therapy sessions scheduled for the client the weeks of 12/7/2014 - 12/20/2014. Client record # 2 contained a treatment plan dated 9/18/2014 that identified the counseling services to be provided as individual therapy sessions bi-weekly. There were no individual therapy sessions scheduled for the client the weeks of 9/21/2014 - 11/15/2014. Client record # 3 contained a treatment plan dated 1/7/2015 that identified the counseling services to be provided as individual and group therapy sessions 2 times per week. The only individual therapy sessions scheduled between the weeks of 1/11/2015 - 2/14/2015 for the client were on 1/12/2015, 1/19/2015, 1/26/2015, 2/2/2015 and 2/9/2015. The only group therapy sessions scheduled between the weeks of 1/11/2015 - 2/14/2015 for the client were on 1/15/2015, 1/22/2015, 1/29/2015, 2/5/2015 and 2/12/2015.Client record # 4 contained a treatment plan dated 7/18/2014 that identified the counseling services to be provided as group therapy sessions 4 times per week. The only group therapy sessions scheduled between the weeks of 7/20/2014 - 8/16/2014 for the client were on 7/21/2014, 7/25/2014, 7/28/2014, 7/31/2014, 8/1/2014, 8/4/2014, 8/7/2014, 8/11/2014, 8/14/2014 and 8/15/2014.Client record # 5 contained a treatment plan dated 6/25/2014 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the week of 7/20/2014 - 7/26/2014. Client record # 10 contained a treatment plan dated 10/21/2014 that identified the counseling services to be provided as group therapy sessions 4 times per week. The only group therapy sessions scheduled between the weeks of 10/26/2014 - 12/6/2014 for the client were on 10/28/2014, 11/4/2014, 11/11/2014 and 12/2/2014. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Site Director will conduct a training for all site clinicians on the proper recording of client's compliance with treatment and rehabilitation plan. Specifically, the training will focus on identifying and recording client's expected attendance, actual attendance, or absence. In the case of absence, notation is to be made in the chart of the clinician's outreach, actual or attempted, and reason for the absence.
2. At the same training, the site Director will advise clinicians of the need to offer services to clients congruent with the treatment and rehabiliation plan when the providing clinician will be absent.
3. Site Director will conduct a monthly random review of ten charts to insure compliance with this requirement. |