INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26, 2009 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 April 28, 2009.
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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 the Department provided core curriculum in clinical supervision for supervisors who have not functioned for two years as supervisors in the provision of clinical services.
Findings:
Five personnel records were reviewed on March 26, 2009. A core curriculum in clinical supervision was required in one personnel record. The facility did not document the core curriculum in personnel record # 2.
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Plan of Correction
The facility director of Northeast Philadelphia will complete the needed hours of clincial supervisor training via the BDAP training program at the next opportunity when this course is offered. Facility director will have this completed by no later than 6/30/09. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to document a minimum of 6 hours HIV/AIDS training and at least 4 hours of tuberculosis/STD training in one of five personnel records.
Findings:
Five personnel records were reviewed on March 26, 2009. 6 hours of HIV/AIDS training and 4 hours of tuberculosis/STD training were required in five personnel records. The facility did not document at least 6 hours of HIV/AIDS training and 4 hours of tuberculosis/STD training in personnel record # 3.
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Plan of Correction
The facility director of Northeast Philadelphia will meet weekly with counselor #3 to insure that she successfully completes her 4 hours of STD/HIV training and 6 hours of HIV training by no later than 6/30/09. Counselor #3 will provide verification that she attended these trainings and the facility director will place the certifications in her personnel file. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to document first aid CPR training for sufficient numbers of staff persons.
Five personnel records and were reviewed and an interview with the facility director was conducted on March 26, 2009. The facility was required to provide first aid and CPR certification to sufficient Numbers of staff persons. The facility documented first aid and CPR certification to only two staff members, #s 2 and 3.
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Plan of Correction
The facility director of Northeast Philadelphia will indentify two additional counselors to attend a CPR and first aid training no later than 5/30/09. The facility director will review with staff members in weekly meetings to be certain that they are seeking out and scheduling appropriate CPR and First Aid trainiings until this is completed. The counselors will provide verification of this training to the facility director who will put the certification in the personel files. |
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, the facility failed to document informed and voluntary consent from the client for the disclosure of information contained in two of six client records.
Findings:
Six client records were reviewed on March 26, 2009. Documentation of informed and voluntary consent from the client for the disclosure of information was required in six client records. The facility did not document informed and voluntary consent from the client for the disclosure of information in client records # 3 and 5.
The facility documented the release of client information to a laboratory, but a signed consent from the client for the release of information was not documented in client records # 4 and 5.
The facility documented the release of case consultation notes to an unspecified individual in client record # 5. The information released exceeded the limitations of 4 Pa Code 255.5 in client records # 5.
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Plan of Correction
The facility director of Northeast Philadelphia will conduct an inservice training on 5/5/2009 for all clinical staff to review documentation regarding informed and voluntary consent for the disclosure of information contained in client records. The counselors will sign off that they attended this training and understand the intent of documenation. The facility director of Northeast Philadelphia will also perform random chart audits until the counselors are 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 five client records.
Findings:
Six client records were reviewed on March 26, 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 that can contribute to the resolution of identified problems in client records # 2 and 3.
The facility did not document a psychosocial evaluation to include the client ' s preferred coping mechanisms in client records # 1, 2, 3, 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 the treatment process in client records # 1, 2 and 3.
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Plan of Correction
The facility director of Northeast Philadelphia will conduct an inservice training on 5/12/09 for all clinical staff regarding the documentation of psychosocial evaluations, with an emphasis on assessing a client's strengths, coping mechanisms, and barriers to treatment. The documentation of counselor's clinical conclusions of a given client's ability to participate in treatment, and the client's attitude toward treatment will also be emphasized during this inservice. |
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 five client records.
Findings:
Seven client records were reviewed on March 26, 2009. Individual treatment plans were reviewed in five client records. The facility did not document an individual treatment plan 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, to indicate the client participated in the development of the treatment plan.
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Plan of Correction
The facility director of Northeast Philadelphia will train all clinical staff to document counselors individual meetings with clients to develop the master treatment plan as well as documentation that clients are met with individually to develop all subsequent treatment plan updates. This training will be held on 5/19/09. All staff will sign off that they attended the training and understand the intent of this documentaion. The facility director of Northeast Philadelphia will perform random monthly chart audits until there is 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 document counseling to clients on a regular and scheduled basis in five of five client records.
Findings:
Six client records were reviewed on March 26, 2009. Counseling on a regular and scheduled basis was reviewed in five client records. The facility did not document counseling on a regular and scheduled basis in client records # 1, 2, 3, 4 and 5.
The facility did not document individual counseling sessions at least once every sixty days to discuss treatment plan updates with clients.
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Plan of Correction
The facility director of Northeast Philadelphia will conduct an inservice training on 5/19/09 for all clinical staff to train them to document their individual meetings with clients every sixty days to discuss treatment plan updates. Clinical staff will also be trained to documetn their counseling of clients on a regualr and scheduled basis, including completing documentation that indicates when a client is absent from treatment and counselors attempts to contact the client by phone or mail. The facility director will conduct monthly chart audits until counselors are in full compliance. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on a review of client records, the facility failed to document a medication record in one of two client records.
Findings:
Six client records were reviewed on March 26, 2009. A Medication record was required in two client records. The facility did not document a medication record in client record #5.
Client record #5 documented Cymbalta, Geodon and Benzotropine prescribed, but the record did not document the dosage of these medications.
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Plan of Correction
The facility director of Northeast Philadelphia will conduct an inservice training on 5/26/09 regarding how to document the name, dosage and frequency of medications in the client record. All staff will sign off that they attended this training and understand the intent of documentation. The facility director will conduct random monthly chart audits until there is 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 two of two client records.
Six client records were reviewed on March 26, 2009. Follow-up information was required in two client records. The facility did not document follow-up information with in seven days of discharge, as stated in the projects policy and procedures manual, in client records # 5 and 6.
Record # 5 was discharged on 2/10/09, but follow-up information was not documented until 2/24/09.
Record # 6 was discharged on 12/1/08, but follow-up information was not documented until 12/20/08.
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Plan of Correction
The facility director of Northeast Philadelhphia will conduct an inservice training on 5/26/09 and train all clinical staff on documentation of follow up contacts with client. Facility director will emphasize that the follow up must be made within seven days of discharge. All staff will sign off that they attended this training and understand the intent of the documentation. The facility director will conduct random monthly chart audits until there is full compliance. |