INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 10 - 11, 2011 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 and a plan of correction is due on March 29, 2011.
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Plan of Correction
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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 the review of the " Staffing Requirements Facility Summary Reports " completed by each facility in the Project, and based on interviews with each facility director 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:
From February 10 through March 3, 2011, the " Staffing Requirements Facility Summary Reports " for each of the thirteen facilities that make up the Project were reviewed. The " Staffing Requirements Facility Summary Reports " list a combined total of 41 counselors and 12 facility directors who are providing drug and alcohol counseling. The total number of drug and alcohol counseling hours per week provided by the counselors and facility directors equates to 39.6 FTE counselors within the project, and therefore the project is required to have at least four full-time clinical supervisors and one part-time clinical supervisor or lead counselor. The " Staffing Requirements Facility Summary Reports " did not identify a full-time clinical supervisor at any of the Project ' s thirteen facilities.
From February 10 through March 3, 2011, interviews with each facility director in the Project were conducted during their respective licensing inspection. Each facility director confirmed that the Project does not have a full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
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Plan of Correction
Rehab After Work will submit a request for appeal. If we are not granted the appeal, the Project Director will ensure that there is 1 full time clinical supervisor for each 8 FTE. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observation, a physical plant inspection and a conversation with the facility director, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of residents, employees and visitors.
The findings include:
A physical plant inspection was conducted on February 11, 2011 at approximately 3 PM.
It was observed during the physical plant inspection that the heating system closet was used for storage.
The facility had stored computers, holiday decorations, bulletin boards with paper attached, a shovel, a lawn mower, desk, chairs, household cleaners, rags, rugs, and numerous boxes.
The facility director confirmed the findings.
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Plan of Correction
The heating system closet will be cleaned entirely. All computers, decorations, bulletin boards, shovels, lawn mower, desk, chairs, household cleaners, rags, rugs, and boxes will be removed from the heating system closet.The heating system closet will be cleaned and nothing will be stored in the heating room closet. The door will be locked so that only authorized personnel will have access to the heating system closet. The site manager will inspect the heating room closetnon a monthly basis to ensure that the standard is met and that the heating system closet remains free from storage. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the hot water temperature in the bathroom did not exceed 120 F.
The findings include:
A physical plant inspection was conducted on February 11, 2011 at approximately 3 PM.
The hot water temperature measured at 160 degrees Fahrenheit.
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Plan of Correction
The hot water heater thermostat will be adjusted to meet the standard and to the proper temperature. The hot water temperature will be measured with a thermometer in all bathrooms so that the water temperature does not exceed 120 F. The site manager will measure the water temperature in the client bathrooms on a random basis to ensure that the water temperature meets the state standard and does not exceed 120 F. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of administrative records and an interview with the Facility Director, the project failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
On February 11, 2011 the project's administrative records were reviewed for a financial audit following the end of their fiscal year. The project's 2009 fiscal year ended on December 31, 2009, but the independent financial audit for this period was not documented at the time of review.
An interview with the Facility Director on February 11, 2011 confirmed that the financial audit had not been documented following the end of the fiscal year.
This is a repeat citation. The facility was cited on March 3, 2010 for failing to document an annual financial audit.
In response to the citation issued on March 3, 2010, the facility provided the following plan of correction:
The executive director shall submit a written request within 90 days for a waiver of this regulation. If the waiver is not granted, then the executive director of Rehab After Work will begin the process of arranging for an independent, external audit with approval from the governing body president. The executive director will monitor progress in the area on a monthly basis and note progress in the governing body minutes (manual).
The facility indicated that they would be in compliance with the standard by 6/30/2010. The facility's exception request as presented, and received on August 25, 2010 was denied. A letter explaining the reason for denial was sent to the facility on September 15, 2010.
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Plan of Correction
The Project Director will acquire the services of a certified public accountant to do an independent audit and include an opinion page for last fiscal year and each fiscal year to follow. The Project Director will assure that these are done on an annual basis |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on the review of personnel records, the facility failed to document a fingerprint based national criminal history record check in one of four records reviewed.
The findings include:
On February 11, 2011 one personnel record requiring a fingerprint based national criminal history record check, due to the facility serving adolescents, was reviewed.
Employee # 3 was hired on August 3, 2010. Based on the Child Protective Services Law (CPSL) Act 73, anyone hired after June 30, 2008, engaging in an occupation with a significant likelihood of regular contact with children, must have a fingerprint based national criminal history record check.
The facility did not document a fingerprint based national criminal history record check in personnel record # 3.
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Plan of Correction
Within thirty days- employee #3 will work with the Human Resource department to register fingerprints with FBI to meet standard as required under PA Act 73. All new employees will register fingerprints as required under PA Act 73. Site manager will work will Human Resource department to ensure that employees are in compliance with standard and Pa Act 73. |
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, and an interview with the facility director, the facility failed to adhere to the requirements specified at 4 Pa. Code relating to specific information disclosed.
The findings include:
On February 11, 2011, eight client records were reviewed to ensure compliance with 4 Pa. Code 255.5. One out of eight client record reviewed failed to adhere to the requirements specified at 4 Pa. Code, specifically client record # 6.
A signed Authorization To Release Information Form in client record # 6 states:
"I here by authorize, Rehab After Work to release/obtain the information stated above."
However, the facility failed to ensure that specific information disclosed was consistently documented on the consent to release form, as the Authorization To Release Information Form failed to indicate what information would be disclosed to a government agency.
The facility director confirmed during an interview on February 11, 2011 that the consent to release form for client # 6 did not document specific information to be disclosed.
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Plan of Correction
At time of state inspection client #6 wwas not an active client. Client had been discharged.Wirhin thirty days, site manager will conduct a staff training on Confidentiality with emphasis on 4 Pa. Code 255.5. Staff will be trained to ensure that the specific information disclosed is consistently documented on the consent to release information form. Counselors will be trained on what specific information an be disclosed and documented on the consent to release form. Counselors will be trained on the Authorization To Release Information Form and they will also be trained to indicate what information would be disclosed to a government agency.
Counselors will be trained to indicate what specific information can be disclosed to a government agency. Site manager will audit client charts on a random basis to ensure that the standard is met. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, and an interview with the facility director, the facility failed to document an informed and voluntary consent from the client for disclosure of information that indicated the purpose of disclosure.
The findings include:
On February 11, 2011, eight client records were reviewed to ensure compliance with 4 Pa. Code 255.5. One out of eight client record reviewed failed to adhere to the requirements specified at 4 Pa. Code, specifically client record # 6.
A signed Authorization To Release Information Form in client record # 6 states:
"I hereby authorize, Rehab After Work to release/obtain the information stated above."
However, the facility failed to ensure that specific information disclosed was consistently documented on the consent to release form, as the Authorization To Release Information Form failed to indicate the purpose of disclosure.
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Plan of Correction
Client #6 was an inactive client at the time of the state audit as counselor failed to ensure the information was properly completed on the Release of Information form.Within thirty days, site manager will conduct a staff training on Confidentiality with emphasis on 4 Pa. Code. Staff will be trained to ensure that the specific information disclosed is consistently documented on the consent to release information form. Counselors will be trained on what specific information can be disclosed and how to properly document such informtion on the release of authorization form. Counselors will be trained on the Release of Information form antd they will be trained to indicate what specific information can be disclosed to indicate the purpose of disclosure on the release of information form.
Site manager will audit client charts on a random basis to ensure that the standard is met. |
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, a review of the facilities policy and procedures manual, and an interview with the facility director, the facility failed to document a complete client record which included an aftercare plan.
The findings include:
The facilities policy titled "Continuing Care Plan" states:
The final phase of treatment is aftercare planning. RAW policy requires that patients develop an effective detailed plan for maintenance of sobriety after completing the program. The primary counselor is responsible for meeting with the patient to develop a detailed continuing care plan for the patient to follow after they leave formal treatment. The continuing care plan is completed within one month of the scheduled discharge date in the context of ongoing individual counseling sessions. The continuing care plan is completed and signed by the patient and counselor before anticipated discharge.
On February 11, 2011, one discharged client ' s record requiring documentation of an aftercare plan was reviewed.
The facility failed to document a complete client record including an aftercare plan in accordance with facility policy in client record # 7.
Client # 7 was admitted to the program on 3/5/10 and discharged on 8/10/10.
Client # 7 successfully completed the program per progress note, discharge summary, and conversation with the facility director and the primary counselor.
At the time of review on 2/11/11 the facility failed to provide a documented aftercare plan.
The facility director confirmed that client # 7's record did not have documentation of an aftercare plan.
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Plan of Correction
Wirhin thirty days, site manager will conduct a staff training on Aftercare Plans contained within the client record. Staff will be educated about the aftercare plan. Counselors will be educated that the "Continuing Care Plan" in the treatment manual states:
"The final phase of treatment is aftercare planning. RAW policy requires that patients develop an effective detailed plan for maintenance of sobriety after completing the program. The primary counselor is responsible for meeting with the patient to develop a detailed continuing care plan for the patient to follow after they leave formal treatment. The continuing care plan is completed within one month of the scheduled discharge date in the context of ongoing individual counseling sessions. The continuing care plan is completed and signed by the patient and counselor before anticipated discharge".
Counselors will be trained to ensure that the Continuing Care Plan guidelines are met and that the state standard is met. Site manager will audit client charts on a random basis to ensure that the standard is met. |