INITIAL COMMENTS
|
This report is a result of an onsite follow-up inspection regarding the plans of correction for the February 14, 2011 licensure renewal inspection. The follow-up inspection was conducted on August 22, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" completed by each facility in the Project, and based on a conversation with the Project Director, 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:The "Staffing Requirements Facility Summary Report" for each of the thirteen facilities that make up the Project was reviewed. The "Staffing Requirements Facility Summary Reports" completed by the facilities on August 11, 2011 list a combined total of 37 counselors and 13 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 42.3 FTE counselors within the project, and therefore the project is required to have at least five 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. The Project Director confirmed during the follow-up inspection on August 11, 2011 that the Project did not have a full-time clinical supervisor for every eight full-time counselors in the Project. The Project Director stated "the Project is financially incapable of hiring a full-time clinical supervisor" for every eight full-time counselors or counselor assistants.This is a repeat citation. The facility was previously cited for noncompliance on February 11, 2011.
|
Plan of Correction
The Executive Director of Rehab After Work is currently awaiting response from the state submitted on 9/16/11 regarding an exception for the Clinical Supervision staffing requirement. If the exception is not granted, the Executive Director will need to restructure current clinical supervision procedures by adding salaried/benefit eligable full-time clinical supervisors per state regulations. The Executive Director will need to obtain Governing Body approval to reorganize salary structures and potentially downsize by closing smaller offices. |
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.
|
Observations
Based on a review of administrative documentation and a conversation with the Project 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:During the follow-up inspection at the administrative offices, which was conducted on August 11, 2011 the project remained out of compliance as Rehab Management Inc. failed to document an annual financial audit by 6/30/11 as indicated in the plan of correction which was approved on 4/8/11. In addition, On February 11, 2011 the project's administrative records were reviewed for a financial audit following the end of their fiscal year. The project's 2009 fiscal year ended on December 31, 2009, but the independent financial audit for this period was not documented at the time of review. The facility was still out of compliance with not having completed a copy of the 2009 financial audit.This is a repeat citation. The facility was cited on March 3, 2010 and February 11, 2011 for failing to document an annual financial audit.
|
Plan of Correction
The current audit has been completed as of 9/23/2011 and finalized results have been placed in the Governing Body Minutes located at the Paoli location. The Executive Director of Rehab After Work has made arrangements with the auditor to ensure that future audits will be completed in a timely fashion in accordance with state guidelines. |
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:
|
Observations
Based on a review of client records, a review of clinical documents, and a conversation with the facility director, the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in client records.The findings include:On August 22, 2011 ten client records were reviewed to ensure that the facility was obtaining informed and voluntary consents.The facility did not obtain an informed and voluntary consent for the disclosure of client information in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.Clients # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 signed and dated an "Authorization To Release Information Form" to a "Managed Care/Insurance Company" which documents allowing the release of "chart contents." The release of "chart contents" fails to ensure that specific information is disclosed; thus the release exceeds the limits imposed by 42 CFR and 28 Pa. Code 709.28In addition, allowing the release of "chart contents" constitutes a general consent to release information. A general consent does not rise to the level of an informed and voluntary consent.The facility director confirmed the findings.
|
Plan of Correction
The site director of Exton office will do monthly trainings starting on 9/7/2011 on the 5 areas of informed consent, to make sure staff is compliant and understands consent. All old non compliant consent forms are destroyed and new ones added to intake packets. All client records audited #1-10 have been modified in regards to managed care consent forms. New state compliant forms have been added to all charts in compliance with consent policy. All charts will be audited on a bi-wekly basis in order to preserve compliance of informed and voluntary consent. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of areas of noncompliance identified during this follow-up licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.The findings include: On August 11, 2011, at the administrative site inspection, the facility was again found to be out of compliance with the following standards: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. This area of noncompliance was also identified during the March 3, 2010 (plan of correction submitted on 3/29/10 and approved on 3/29/10) and February 11, 2011 (plan of correction submitted on 4/7/11 and approved on 4/8/11) licensing inspections.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. This area of noncompliance was also identified during the February 11, 2011 licensing inspection. The plan of correction was submitted on 4/4/11 and approved on 4/6/11.
|
Plan of Correction
The current audit has been completed as of 9/23/2011 and finalized results have been placed in the Governing Body Minutes located at the Paoli location. The Executive Director of Rehab After Work has made arrangements with the auditor to ensure that future audits will be completed in a timely fashion in accordance with state guidelines.
The Executive Director of Rehab After Work is currently awaiting response from the state submitted on 9/16/2011 regarding an exception for the Clinical Supervisor staffing requirement. If exception is not granted, the Executive Director will need to restructure current clinical supervision procedures by adding salaried/benefit eligable full-time clinical supervisors as per state regulations. The Executive Director will need to obtain Governing Body approval to reorganize salary structures and potentially downsize by closing smaller offices.
The site director of Exton office will do monthly trainings starting on 9/7/2011 on the 5 areas of informed consent, to make sure staff is compliant and understands consent. All old non compliant consent forms are destroyed and new ones added to intake packets. All client records audited #1-10 have been modified in regards to managed care consent forms. New state compliant forms have been added to all charts in compliance with consent policy. All charts will be audited on a bi-wekly basis in order to preserve compliance of informed and voluntary consent.
|