INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 29, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD Lower Merion Counseling Services 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:
|
Plan of Correction
|
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
|
Observations
Based on a review of personnel records, the facility failed to ensure the project director and facility director met the qualifications of the positions at the time of hire in one of one applicable personnel records reviewed.
Employee # 1 was hired as the project director on December 22, 2025. The employee had a bachelor's degree with a major in individualized studies, which is not a qualifying major. Additionally, the employee did not have documentation indicating they had any experience in both the supervision of others and direct service.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
An exemption request for Project Director was submitted on 2/18/26.
Follow up was received they are reviewing.
LMCMS Facility Director or Clinical Director will work with RHD Compliance Department assure anyone listed as the Project Director meets the qualifications and/or request exceptions prior to listing the Project Director.
If the Project Director changes, the Facility Director or Clinical Director will work with RHD Compliance to identify the Project Director that meets the qualifications.
If the exception request is not approved, then the Facility Director or Clinical Director will designate a qualified individual to serve as Project Director. Qualifications will be verified with RHD Compliance prior to listing a Project Director moving forward.
|
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on an administrative review, the project failed to ensure the project director annually updated and signed the written manual which delineates the project's policies and procedures.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
An exemption request for Project Director was submitted on 2/18/26.
Follow up was received they are reviewing.
Once approved Project Director will sign off on manual within two weeks of the approval.
LMCMS Facility Director or Clinical Director will work with RHD Compliance Department assure anyone listed as the Project Director meets the qualifications and/or request exceptions prior to listing the Project Director.
If the Project Director changes, the Facility Director or Clinical Director will work with RHD Compliance to identify the Project Director that meets the qualifications.
If the exception request is not approved, then the Facility Director or Clinical Director will designate a qualified individual to serve as Project Director. Qualifications will be verified with RHD Compliance prior to listing a Project Director moving forward. Facility Director or Clinical Director will assure the Policy and Procedure Manual will be reviewed and signed off on the Policy and Procedure Manual annually by the Project Director. The audit of this will be done annually by the Clinical Director or D&A Clinical Manager.
|
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
|
Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.
Client # 4 was admitted on April 21, 2025 and was administratively discharged on July 31, 2025. There was no documentation in the record indicating the client was given an opportunity to request reconsideration of the facility decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
D&A Clinical Manager, Clinical Director, QA Manager, and Unit Director will review the current grievance and appeal policy to ensure it reflects the current and accurate grievance and appeal process. This review will occur in March 2026. This policy is currently in the program's intake packet, and clients sign off on reviewing this policy before beginning treatment. This process will continue to exist. D&A Clinical Manager and Clinical Director will edit and update the administrative discharge letter template for use in the event of an administrative discharge. The aforementioned parties will be in consultation with each other regarding any client concerns that may warrant an administrative discharge, and notify the client's insurance provider(s) of a potential administrative discharge. Clinical Director and D&A Clinical Manager will review the template for an administrative discharge notification letter and add the grievance and appeal policy as an addendum to this letter. When the letter is sent to the participant, a note about this correspondence will be added to the client's chart in the electronic health record, including documentation that the grievance and appeal policy was sent to the client. A copy of the letter and grievance and appeal policy sent to the client will also be uploaded to the electronic health record. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of seven client records reviewed.
Client # 1 was admitted on September 23, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 9, 2025; however, the plan did not include the frequency of treatment services.
Client # 2 was admitted on May 2, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 15, 2025; however, the plan did not include the frequency of treatment services.
Client # 3 was admitted on June 24, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 23, 2025; however, the plan did not include the frequency of treatment services.
Client # 7 was admitted on May 15, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 22, 2025; however, the plan did not include the frequency of treatment services.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
D&A Clinical Manager will conduct a training to review best practices to complete D&A treatment plans for all D&A clinicians in March 2026. This training will highlight the need to include frequency of treatment in treatment plan items. D&A Clinical Manager will create a job aid for best practices to complete D&A treatment plans, including the importance of including frequency of treatment in these plans. This job aid will include examples of appropriate D&A treatment plan objectives and interventions for D&A therapists to use as a template to model their D&A treatment plans off of with D&A clients to ensure frequency of treatment is included in the aforementioned plans. D&A Clinical Manager will review all D&A treatment plans within the electronic health record before they are finalized. If a D&A treatment plan is submitted without frequency mentioned in said plan, D&A Clinical Manager will reject the D&A treatment plan for the submitting clinician to review and make necessary revisions to ensure frequency is reflected in treatment plan items. The D&A Clinical Manager will consult with Clinical Director on a regular basis to determine if any further training is needed to support staff with ensuring completion of D&A treatment plans include frequency of treatment. |