INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 17, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab After Work 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 ________________________________________________________.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to document that the facility director, who functions as the clinical supervisor, completed a core curriculum in clinical supervision.Findings:Personnel records were reviewed on March 3, 2009. The facility director/clinical supervisor did not document 2 years experience as a supervisor in the provision of clinical services prior to being hired for the position in 1/07. The facility failed to document that the facility director/clinical supervisor completed a core curriculum in clinical supervision.
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Plan of Correction
Site Director of Exton will attend core curriculum supervison training as per BDAP licensing requirements. Should the facility consider hiring additional clinical supervisors the facility will ensure that the incumbent have the required supervisory experience prior to thier assuming the position or that they complete the required core curriculum training within six months of becoming a clinical supervisor. The Executive Director of Rehab After Work and Human Resources will monitor for compliance. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of supervision notes, the facility failed to document close supervision in the counselor assistant personnel record.Findings:One personnel record and supervision documentation was reviewed on March 3 and March 17, 2009. Close supervision of one hour direct observation was required for one counselor assistant, #3. The facility documented formal supervision notes for May 2009 through February 2009. Employee #3 was hired on 5/1/08. Supervision notes did not document direct observation from date of hire. Progress notes were reviewed for client record #2 which did not document direct observation. A conversation with the facility director/clinical supervisor on 3/17/09 confirmed that direct observation did not take place. The facility documented a high school diploma for employee #3 which requires documentation of nine months of close supervision which includes one hour per week of direct observation.
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Plan of Correction
Effective immediately the Exton Site Director will provide weekly observation of one hour of clinical service delivery for employee number 3 (Counselor Assistant)-- Supervision will be documented in a special log. The Exton facility will ensure that future Counselor Assistants will follow the same process of direct observation and documented supervision to be implemented and managed by the Exton Site Director. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of staff training records, the facility failed to document potential resources in individual training plans for five of seven training records reviewed.Findings:Seven training records were reviewed on March 17, 2009. Individual training plans which include potential resources were required for seven employees. The facility failed to document potential resources in the individual training plans for employees #2, 3, 4, 7 and 8.
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Plan of Correction
Site Director will meet with clinical staff to review Individual Training Plan and instruct them on the planning process noting how to identify training resources and schedule attendence. the site Director of Exton will ensure that training providers/ resources are included on the Training Plans. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection, the facility failed to ensure that there were no heaters which were not permanently mounted or installed.Findings:The physical plant inspection was conducted on March 17, 2009 between 10 and 10:30 AM. A space heater was found in employee #3's office.
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Plan of Correction
Effective immediately the Site Director of Exton will assure that the space heater will be removed from the facility / employee number 3 office. The Site Director will review regulations with staff on 4-15-09 regarding physical plant requirements.The site will be checked weekly to ensure that there are no space heaters on the premises. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
.Based on the review of the fire drill records and an interview with the facility director, the facility failed to document that the smoke detector was set off during each fire drill.Findings:The fire drill records were reviewed on March 17, 2009. An interview with the facility director regarding the fire drills was conducted on March 17, 2009. The facility failed to document that the smoke detector was set off during each fire drill. The facility director stated that the smoke detectors were not set off during the fire drills and that the facility was using an alternate means of announcing the fire drills. The facility director failed to provide documentation that the alternate means was approved by the Department of Health. The facility director also failed to document the annual inspection of the smoke detectors.
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Plan of Correction
The Site Director of Exton will draft a letter and forward to the Dept of Health requesting that an alternate means of announcing fire drills be implemented at Exton location. Also, annual inspections of the inspections of the smoke detector system will be kept in a fire safety section of the site director's Log with approved documentation that the system is in working condition. |
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 and the review of the Business Associate Agreement with Calloway Labs, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of eight client records reviewed. The facility also used consents to release information forms which contained "obtain from" language in six of eight client records reviewed. The facility also documented a parent's signature on the consent to release form in one client recordFindings:Eight client records were reviewed on March 16, 2009. The Business Associate Agreement with Calloway Labs was reviewed on March 4, 2009. The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to Calloway Labs in client records #2, 5 and 6. The Business Associate Agreement with Calloway Labs only referenced HIPAA regulations and did not comply with 42 CFR Part 2 Subpart B Subsection 2.12(c) (4) and 4 Pa. Code The consent to release information forms also contained "obtain from" language in client records #1, 2, 3, 4, 5 and 6. The consent to release information to the funding source was signed by the adolescent client's father in client record #2.
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Plan of Correction
The Executive Director of Rehab After Work will work with calloway labs Associate to include language pertaining to 42 CFR Part 2 Subpart B Subsection 2.12(c)(4). Effetive immediately, the Site Director of Exton will inform all staff to have each client sign a consent to release from for exchange of information with calloway labs. This will be done until a new agreement has been recieved by the facility. A copy of the new agreement will be kept on site. Also, the consent to release information forms will be reprinted without the language "obtained from" on them. The Executive Director will monitor progress on both tasks until we are in full compliance with the standard. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in five of eight client records reviewed.Findings:Eight client records were reviewed on March 17, 2009. An informed and voluntary consent from the client for the disclosure of information contained in the client record was required in six client records. The specific information to be released to the funding source exceeded 255.5 Pa Code in in client records #2, 3, 4, 5 and 6. The information to be released to the managed care agency included "level of care evaluations, authorizations, status reports and recommendations."
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Plan of Correction
Site Director of Exton will conduct an inservice training on 4-28-09 on confidentiality and comliance with 255.5 regulations in the PA Code. All staff will sign off they attendend the training and understand disclosure of information and informed consent. The Site Director of Exton will conduct random monthly chart audits until the facility is in full compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in five of eight client records reviewed.Findings:Eight client records were reviewed on March 17, 2009. Psychosocial evaluations were required in five client records. The facility did not document a psychosocial evaluation in client records # 1, 2, 3, 4 and 5.The facility did not document a psychosocial evaluation to include the client ' s assets/strengths in client records # 1, 2, 3, 4 and 5.The facility did not document a psychosocial evaluation to include the client ' s support systems in client records #1, 2, 3, 4 and 5.The facility did not document a psychosocial evaluation to include the client ' s coping mechanisms in client records # 2, 3 and 4.The facility did not document a psychosocial evaluation to include the client ' s negative factors in client records # 1, 4 and 5.The facility did not document a psychosocial evaluation to include conclusions regarding the client ' s attitude towards and ability to participate in treatment in client records #2, 4 and 5.The facility did not document a psychosocial evaluation to include the counselor conclusions and impressions in client records #1, 2, 3, 4 and 5.
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Plan of Correction
Site Director of Exton will conduct in-service on the development of a full psychosocial document including all required information in the format advised by PA Dept of Health highlighting strenghts, negative factors, supports, motivation and clinical impressions and conclusions. Date of inservice to be 4-29-09. Site Director to audit charts randomly on a monthly basis until facility is within full compliance. |
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 document an individual treatment and rehabilitation plan developed with the client in five of eight client records.Findings:Eight client records were reviewed on March 17, 2009. An individual treatment and rehabilitation plan developed with the client was required in five client records. The facility did not document treatment plans developed with the client in records # 1, 2, 3, 4 and 5.The treatment plans were not signed by the client, and there was no documentation, in the client ' s progress notes, of the client participating in the development of the treatment plan.
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Plan of Correction
The Site Director of Exton will train all clinical staff on the procedure of meeting with the client to develop the treatment plan and to document via progress note that the initial meeting took place on 4-15-09 and will be reviewed again for absent staff on 4-22-09. All staff will sign off that they attended this trianing and understand the intent of this documentation.The Site Director of Exton will perform random monthly chart audits until there is full compliance. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include proposed types of supportive services in three of eight client records. Findings:Eight client records were reviewed on March 17, 2009. Treatment plans with proposed types of supportive services were required in five client records. The facility did not document treatment plans with proposed types of supportive services in client records #1, 3 and 4.
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Plan of Correction
The Site Director of Exton will train staff to document proposed supportive services in treatment plans on 4-22-09. The Site Director of Exton will perform monthly random audit of charts until facililty is in full 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.
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Observations
Based on the review of client records, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan on the treatment plan update in five of eight client records reviewed.Findings:Eight client records were reviewed on March 17, 2009. An assessment of the client's progress in relationship to the stated goals of the prior treatment plan was required in five client records. The facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan in client records #1, 2, 3, 4 and 5.
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Plan of Correction
The Site Director of Exton will train clinical staff on preparation of treatment plan updates to include specific progress on each stated treatment goals of the prior treatment plan update or master treatment plan. Training will take place on 04/22/09. The Site Director of Exton will perform random monthly chart audits until facility is in full compliance. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to document that counseling was provided to a client on a regular and scheduled basis in four of eight client records.Findings:Eight client records were reviewed on March 17, 2009. Counseling provided to a client on a regular and scheduled basis was required in six client records. The facility failed to document at least one individual session every 60 days for the completion of the comprehensive treatment plan and treatment plan update in client records # 2, 3, 4 and 6.
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Plan of Correction
The Site Director of exton will train all clinical staff on 4-22-09 on the process of documenting individual client counseling meetings on a 60 day basis to review comprehensive treatment plan and treatment plan updates. All staff will sign off on the attendence of this training. Site Director of Exton will perform random monthly audits until facility is in full compliance. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of four client records where required.Findings:Eight client records were reviewed on March 17, 2009. Follow-up information was required in four client records. The facility failed to document follow-up information within the 7 days from discharge as per policy in client record #6. The facility failed to document follow-up information in client records #7 and 8.
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Plan of Correction
The Site Director of Exton will train all clinical staff on post discharge follow-up documentation on 4-22-09. Staff will sign off on attendence. Site Director of Exton will perform monthly chart audits until facility is in full complaince. |