INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab After Work 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 the company is not granted an appeal, the Project Director will ensure that there is 1 full-time clinical supervisor for every 8 FTE. |
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 February 10, 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 aquire the services of a certified public accountant to do an independent audit and include an opinion page for the last fiscal year and each fiscal year to follow. The Project Director will assure that these are done on an annual basis. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document a fingerprint based national criminal history record check in one of two records. The findings include:On February 14, 2011 two personnel records were reviewed for fingerprint based national criminal history record checks. The facility did not document a fingerprint based national criminal history record check in personnel record #3. Personnel #3 was hired after June 30, 2008, and because he is engaging in an occupation with a significant likelihood of regular contact with children, he is required to have a fingerprint based national criminal history record check.Personnel #3 was hired on 4/1/10. Based on the Child Protective Services Law (CPSL) Act 73, anyone hired after June 30, 2008, engaging in an occupation with a significant likelihood of regular contact with children, must have a fingerprint based national criminal history record check. The facility did not document a fingerprint based national criminal history record check in personnel record # 3. An interview with the facility director on February 14, 2011 confirmed that personnel record #3 did not contain a fingerprint based national criminal history record check.
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Plan of Correction
Site Director of Exton Rehab After Work will have all staff complete FBI fingerprinting form and submit it. all new hires of the Exton office will be required to be cleared by the FBI and have documents stating this in their personnel file before they are allowed to carry a caseload in Exton at Rehab After Work. Site director will monitor weekly until standards are met. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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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 treatment plan to include a proposed type of support service in four of six client records.The findings include:On February 14, 2011 treatment plans in six client records were reviewed for proposed types of support services. All six records required treatment plans to include a proposed type of support service. The facility did not document a proposed type of support service on treatment plans, as per facility policy, in client records # 1, 2, 3 and 6.The facility policy titled " Comprehensive Treatment Plan " states: " The Comprehensive Treatment Plan is an individual treatment and rehabilitation plan developed in collaboration with each patient and their assigned primary counselor. The plan shall include, but not be limited to, written documentation of:1.Short and long term goals for treatment as formulated by both the Primary Counselor and the Patient. Goals should be realistic and stated in terms of measurable criteria.2.Type and frequency of treatment and rehabilitation services.3.Proposed type of support service. Services may include medical, psychiatric or mental health services, financial, legal, AA, NA, etc. "In client record #1, the treatment documented on 11/17/10 did not include a proposed type of support service. In client record #2, the treatment documented on 11/23/10 did not include a proposed type of support service. In client record #3, the treatment documented on 12/3/10 did not include a proposed type of support service. In client record #6, the treatment documented on 11/10/10 did not include a proposed type of support service. An interview with the facility director on February 14, 2011 confirmed that the treatment plans in the identified client records did not include a proposed type of support service.This is a repeat citation. The facility was cited on March 24, 2010 for failing document a proposed type of support service on treatment plans.In response to the citation issued on March 24, 2010, the facility provided the following plan of correction: The site director of Exton will begin training immediately. An inservice on the proper way to document treatment plans, including proposed support services will be conducted on 4/15/2010. All staff at Exton office are required to attend training and sign off that they understand the intent of this standard. The site director will conduct random audits of charts until the office is in full compliance.
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Plan of Correction
The site director of Exton RAW will immediately begin training. An inservice on the proper way to document treatment plans, giving special attenition to notating support services. This will be conducted regularly on a bi-monthly basis every wednesday at 12:30p during site supervision. The first will be held 5/1/11, and will be conducted by site director. The site director will conduct random audits until site is in full compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records and in interview with the facility director, the facility failed to document a treatment plan update in five of five client records.The findings include:Five client records were reviewed on February 14, 2011 for documentation of treatment plan updates. The facility did not document a treatment plan update, as per facility policy, in client records # 1, 2, 3, 4 and 5. The facility's policy titled " Treatment Plan Review and Update " states:1.The Comprehensive Treatment Plan shall be reviewed and updated at least every 60 days.2.The Comprehensive Treatment Plan review and update should include an assessment of the patient's progress in relationship to the stated goals of the planIn client record #1, the treatment plan update documented on 1/13/11 did not include an assessment of the patient's progress.In client record #2, the treatment plan update documented on 2/1/11, did not include an assessment of the patient's progress.In client record #3, the treatment plan update documented on 2/2/11 did not include an assessment of the patient's progress.In client record #4, the treatment plan updates documented on 11/14/10 and 1/14/11 did not include an assessment of the patient's progress.In client record #5, the treatment plan update documented on 11/16/10 did not include an assessment of the patient's progress.An interview with the facility director on February 14, 2011 confirmed that the treatment plan updates in the identified client records did not include and assessment of the patient's progress.
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Plan of Correction
The Site Director of the Exton office will begin training immediately on how to properly create, document treatment plans for client charts. Particularly in regards to examples for client records #1-#5 in addressing client progress specifically. This specific area was not documented and will be addressed via this corrective action.
The site director will give a 45 minute training on 5/1/2011 to adress this issue and also randomly audit clinicians charts to hold everyone accountable to change. The site director will conduct random chart audits until site is in compliance. |