INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 4-6,2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, 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 6, 2009.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of employee personnel and training files during the onsite licensing inspection , the facility failed to document the required period of supervision for each counselor assistant.
The findings included:
Agency personnel and training files were reviewed for two counselor assistants employed at this facility. One of the counselor assistants (# 3), had only three months of the required six months of close supervision documented in her personnel record.
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Plan of Correction
The project director and chief counselor are responsible to ensure compliance in documentation of counselor/counselor assistant supervision. In order to obtain and remain in compliance the facility will require documentation of supervision recieved at any other employment to be recieved, reviewed, and filed in the employee chart before granting credit for that supervision at this facility. In this particular case the counselor assistant will recieve an additional three months of supervision from the cheif counselor and project director. Once this is acheived the counselor assistant will have recieved the required 6 months and we will be in full compliance with this standard. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on the review of the agency policy and procedure manual on February 2, 2009, the facility failed to document that the annual report was made available to the public.
The findings included:
The agency policy and procedure manual was reviewed during the onsite licensing inspection of February 2 -6, 2009. There was no documentation that the annual report was made available to the public for the calendar year reviewed.
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Plan of Correction
The governing body of the organization is responsible to ensure that the annual report is made available to the public. In order to obtain compliance once the taxes are completed and recieved by the CEO the statement of income and expenses will be provided to the project director who will attach it to the annual report and ensure that an advertisement is placed in the news paper. A copy of the advertisement will be obtained and retained in the corportate records to ensure that this documentation is available in the future for any licensing inspection. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to document complete drug and alcohol histories in seven of eleven client records.
The findings included:
Eleven client records were reviewed during the onsite licensing inspection of February 4-6, 2009.
Lengths and patterns of use for each illicit drug reported by the client was not documented in client records # 1, 2, 3, 6, 7, 10 and 11.
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Plan of Correction
The Drug History will be reviewed by the project director and updated as necessary to improve identification of lengths and patterns of use for clients drug history. The project director will then review the form with staff and disuss documentation of lengths and patterns of use during client intake. Chart audits will be conducted to ensure that the documentation is improved and that the staff is following the new guidlines for collection of the drug history information. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to document complete personal histories in ten of eleven client records.
The findings included:
Eleven client records were reviewed during the onsite licensing inspection of February 4-6, 2009.
Family dynamics were not documented as part of the family history in client records # 1, 2, 4,6,7,10 and 11.
Employment histories were not documented in client records # 1, 2, 3, 4, 6, 7, 8, 9 and 10.
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Plan of Correction
The project director is responsible to ensure compliance with this regulation. The project director will review and update the intake documentaion of clients personal histories and determine the need for any changes in the policies and procedures or the intake forms. The staff will then be trained on the collection of information from clients during the intake process and be made aware of any updates or changes to policy and procedures of forms. To ensure future compliance random chart audits will be performed to review the completeness of all intake documentation. |
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 the client records, the facility failed to document psychosocial evaluations which provided a complete clinical assessment of each client in nine of eleven client records.
The findings included:
Eleven client records were reviewed during the onsite licensing inspection of February 4-6, 2009.
Client needs which identified possible relationships, conditions and causes leading to the client's current situation were not documented on the psychosocial evaluations in client records # 1, 2, 4, 6, 7, 8, 9, 10 and 11.
Client strengths and assets which could contribute to the resolution of identified problems were not documented on the psychosocial evaluations in client records # 2, 4, 6 and 8.
Client support systems were not documented on the psychosocial evaluations in client records # 6 and 8.
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Plan of Correction
The project director is responsible to ensure compliance with this regulation. The project director will review and update all intake information collection forms and the psychosocial form and determine the need for any changes in the policies and procedures or the intake forms. The staff will then be trained on the collection of information from clients during the intake process and be made aware of any updates or changes to policy and procedures of forms. To ensure future compliance random chart audits will be performed to review the completeness of all intake documentation. |