INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 30, 2010 through July 1, 2010 licensure renewal inspection. The follow-up inspection was conducted on January 12, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 and a plan of correction is due on February 6, 2011.
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Plan of Correction
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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
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction.
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Plan of Correction
The Annual Audit will be made available by the Corporate Budget Analyst prior to the end of the fiscal year ending on June 30th of that year. If for some reason unforeseen circumstances the audit will not be made available by that date, a request for an extension will be submitted. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel files and a interview with the facility director, the facility failed to meet the requirements of this regulation as evidenced by the absence of annual performance reviews in two of ten records.
The findings include:
Ten personnel records were reviewed on January 12, 2011. Annual performance reviews were required in two records, #1 and 2. Per the facility's policy and procedure annual, performance reviews are done yearly on an employee's anniversary date.
According to documentation revealed in employee record # 1, the last documentation of an annual performance review was documented September 5, 2008.
According to documentation revealed in employee record # 2, last documentation of their annual performance review was documented June 3, 2009.
The facility director confirmed this during the follow-up inspection.
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Plan of Correction
Supervisors will do yearly performance reviews for each individual employee on the employee's anniversary date.
To ensure the timely completion of this task, the agency's Operations Manger, as well as each employee, will be responsible for notifying supervisors of upcoming reviews at least 2wks prior to the review date.
All staff will be educated of this procedure at an upcoming staff meeting.
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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 complete psychosocial evaluations in one of three client records reviewed.
The finding includes:
Three records were reviewed on January 12, 2011. Psychosocial evaluations were required in one record reviewed, #2. Also, per the facility's policy and procedure manual, the psychosocial evaluations are done at intake.
Client record #2 failed to document the composite picture of the client, the clients problems and needs, assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment, the clients attitude towards treatment and the counselors conclusion and impressions of the client.
The facility director confirmed this during the follow-up inspection.
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Plan of Correction
All staff will be reeducated at an upcoming staff meeting about completing intake assessments and psychosocial evaluations in their entirety at the time of intake.
Additionally, the individual staff members responsible for the charts in question will meet with their supervisor for further education and development in this matter.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to conduct a case consultation in two of three client records.
The findings include:
Three client records were reviewed on January 12, 2011. Cases consultations were required in two client records. Per the facility's policy and procedure manual, case consultations are to be documented every 90 days from the client's admission date.
Client #1 was admitted on April 27, 2010 and their case consultation was to be completed by July 27, 2010 and October 27, 2010; there was only one documentation of case consultations on November 9, 2010.
Client #2 was admitted on October 1, 2010 and their case consultation was to be completed by January 1, 2011: there was no documentation of case consultation in client record #2.
The facility director confirmed this during the follow-up inspection.
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Plan of Correction
All staff will be reeducated at an upcoming staff meeting about completing performing & documenting case consultations at least every 90days.
Additionally, the individual staff members responsible for the charts in question will meet with their supervisor for further education and development in this matter.
To ensure this problem does not recur, the CQI Specialist will review all charts monthly for case consultations. |