INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 3, 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.
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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
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 10, 2011 the Project ' s administrative records were reviewed for a financial audit following the end of their fiscal year. The Project ' s 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 March 3, 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 24, 2010 for failing to document an independent financial audit.
In response to the citation issued on March 24, 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. |
709.91(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 the review of client records and an interview with the facility director, the facility failed to document a psychosocial evaluation in six of six client records.
The findings include:
On March 3, 2011 six client records were reviewed for documentation of psychosocial evaluations. The facility did not document a psychosocial evaluation to include a complete composite description of the patient, as per facility policy, in client records # 1, 2, 3, 4, 5 and 6.
The facility ' s policy titled " Psychosocial Evaluation: Narrative Summary Evaluation ' states:
" Within 14 days of the date of admission, the primary Counselor completes a written Biopsychosocial Assessment which yields a complete composite description of the patient in relation to the collected information. The summary includes the Counselor ' s impressions, conclusions, observations, and interpretations of historical and other pertinent data. The Evaluation includes:
clear description of the patient ' s presenting and underlying problems
' s needs or problems that cannot be resolved through treatment or that might inhibit treatment
' s assets, strengths or other factors that can contribute to the resolution of identified problems.
potential of available patient support system
factors that might affect treatment
patient ' s preferred coping mechanisms
regarding the patient ' s appearance, behavior and reactions during the intake process
regarding the patient ' s attitude toward and ability to participate in the treatment process. "
The psychosocial evaluation in client record #1, dated 10/13/10 did not include (1) the client ' s preferred coping mechanisms and (2) negative factors that might affect treatment.
The psychosocial evaluation in client record #2, dated 8/18/10 did not include (1) the client assets, strengths or other factors that can contribute to the resolution of identified problems, (2) the client ' s preferred coping mechanisms and (3) negative factors that might affect treatment.
The psychosocial evaluation in client record #3, dated 10/2/10 did not include (1) the client assets, strengths or other factors that can contribute to the resolution of identified problems, (2) negative factors that might affect treatment.
The psychosocial evaluation in client record #4, dated 10/15/10 did not include (1) the client assets, strengths or other factors that can contribute to the resolution of identified problems and (2) the client ' s preferred coping mechanisms.
The psychosocial evaluation in client record #5, dated 1/18/11 did not include (1) the client assets, strengths or other factors that can contribute to the resolution of identified problems, (2) the client ' s preferred coping mechanisms and (3) negative factors that might affect treatment.
The psychosocial evaluation in client record #6, dated 10/1/10 did not include (1) the client assets, strengths or other factors that can contribute to the resolution of identified problems, (2) the client ' s preferred coping mechanisms and (3) negative factors that might affect treatment.
An interview with the facility director on March 3, 2011 confirmed that the identified client records did not include a psychosocial evaluation with a complete composite description of the patient.
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Plan of Correction
The facility director of Northeast Philadelphia will conduct an inservice training on 3/24/11 for all clinical staff regarding the documentation of psychosocial evaluations with an emphasis on assising a client's presenting and underlying problems, strengths, supports, coping mechanisms and barriers to treatment. The training will also emphasize ways in which a counselor can articulate his or her clinical conclusions of a given client's ability to participate in treatment and the client's reaction to the intake process.
The facility director will audit charts monthly to assure compliance. The facility director will review again in staff meeting with counselors on an individual basis as needed if further action is needed. |