INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20, 2012 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:
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Plan of Correction
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to document a confidentiality policy and procedure compliant with 4 Pa. Code subsection 255.5.
The findings included:
4 Pa. Code subsection 255.5 (a)(6), states: "Projects may disclose with the consent of a client, in writing, the information to employers of a client to further the rehabilitation of a client; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Such information shall be limited to whether the client has or is receiving treatment with the project."
The facility policy and procedure manual was reviewed as part of the annual onsite licensing inspection of March 5 - 6, 2012. Policy # 60,006, section C, subsection 2, letter f, exceeded 4 Pa. Code subsection 255.5 (a)(6), as it allowed for the following: "Life Management may disclose with the client's consent, the information to employers of a client to further the client's rehabilitation; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Information released shall be limited to that provided for in subsection 4.a. in this section."
Subsection 4.a. states: " Nature of Client Information to be Disclosed. a. Information released to judges, probation or parole officers, insurance company, health or hospital plan or government officials, pursuant to section C.2.a-i of this section, is for the purpose of determining the advisability of continuing th client in treatment with Life Management and shall be restricted to the following:
i. Whether or not the client isn't in therapy
ii. The prognosis of the client
iii. The nature of the project
iv. A brief description of the client's progress
v. A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse."
The project's Confidentiality policy permits for the release of information under ii, iv, and v, which is restricted under 4 PA Code 255.5(a)(6).
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Plan of Correction
The Executive Director of Rehab After Work will change the policy & procedures section in our manual (#66006) to reflect that "information specifically released to employers will be limited to whether a client has or is recieving treatment with the project". This will be circulated to all offices.
All staff will be required to attend a 6 hour training on Confidentiality (255.5) on 4/13/2012 presented at our Phoenixville location. This policy addendum will be reviewed for all staff as part of the training.
Site directors will perform random, monthly charts audits to ensure that this policy change is being reflected by all clinicians. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and the facility ' s policies and procedures, the facility failed to document an aftercare plan in accordance with the project ' s policies and procedures.
The findings include:
In reference to aftercare plans the project ' s policy states:
A Continuing Care Plan is to be completed within one month of the scheduled discharge date ....in relation to ongoing individual sessions. To be completed and signed by the counselor and client prior to discharge.
On March 19, 2012 one client record was reviewed for an aftercare plan. One out of one client record lacked documentation of an aftercare plan, specifically client record # 4.
Client #4 was admitted on May 16, 2011 and discharged on August 8, 2011. An aftercare plan was due to be documented by August 8, 2011. At the time of inspection, there was no documentation of an aftercare plan for client #4.
The findings were confirmed by the Site Director during the exit interview.
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Plan of Correction
Training will begin immediately and will be ongoing. The site director of the Jenkintown office will review policy regarding the completion of aftercare plans in a staff training on 4/17/12. All counselors will participate in the training and sign off that they understand the guidelines regarding aftercare plans.
The site director will follow up with monthly, random chart audits to ensure that the standard is being met. Charts audits will be ongoing until the center 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 and the facility ' s procedures, the facility failed to document a follow-up in accordance with the project ' s procedures.
The findings include:
In reference to follow-ups the project states:
"A follow up is to be documented in 7 days for all clients, regardless of discharge status."
On March 19, 2012 three client records were reviewed for documentation of a follow-up. One out of three client records lacked documentation of a follow-up, specifically client record # 5.
Client #5 was admitted on June 20, 2011 and discharged on August 5, 2011. A follow-up was due to be documented by August 12, 2011, as of the date of the inspection, there was no follow-up documented for client # 5.
The findings were confirmed with the site director during the exit interview.
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Plan of Correction
Training will begin immediately and will be ongoing. The site director of the Jenkintown office will review the policy regarding client follow-up in a staff training on 4/17/12. All counselors will participate in the training and sign off that they understand the guidelines regarding documentation of client follow-up.
The site director will follow up with monthly, random chart audits to ensure that the standard is being met. Charts audits will be ongoing until the center is in full compliance. |
704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" (SRFSR) for all of the facilities in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
The findings include:
The SRFSR for the fourteen facilities that make up the project list a total of 57 counselors (some full time and some part time) and fourteen part-time clinical supervisors. The total of the hours per week provided to the project by counselors equates to 46 FTE counselor positions within the project.
The SRFSR for the fourteen facilities within the project revealed that no employees were listed as a full-time clinical supervisor. The SRFSR listed each of the fourteen part-time clinical supervisors as facility directors; therefore they are unable to provide full-time clinical supervision. In addition nine of those part-time clinical supervisors carried a caseload above five clients, which further prevents their ability to provide full-time clinical supervision to their staff. A full-time equivalency of 46 counselors would require a minimum of 5 full-time clinical supervisors and one part-time clinical supervisor within the project.
This finding was confirmed with the project director during the administrative review.
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Plan of Correction
The facility is requesting an exception to this standard. If an exception is not granted, the project will ensure that there is one full time Clinical Supervisor for every 8 FTEs. Should the exception not be granted, the Project Director will monitor the staff schedules to ensure compliance with the licensing standard 704.6(a) as written.
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