INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD Lower Merion Counseling Services 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:
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training, during the facility ' s January 1, 2024 through December 31, 2024 training year, in one of seven applicable personnel records reviewed.
Employee # 7 was hired as a counselor on April 3, 2023. The personnel record documented 18.6 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The training year for the facility has been revised to be January 1st-December 31st for all D&A staff. This will be communicated to all D&A staff by 2/28/2025 by D&A Clinical Manager, Clinical Director, and/or their supervisor in individual supervisions and reviewed regularly in consistent supervisions with their supervisor. D&A Clinical Manager will also email all D&A staff about the update to the training year. All D&A staff will submit their training certificates to the internal training system as well as submit a copy via email to their staff file at a minimum of every quarter. When sending training certificates via email to their staff file, they will include D&A Clinical Manager, their supervisor (if different than D&A Clinical Manager), and Clinical Director. All D&A staff members will complete a quarterly training feedback survey that is reviewed quarterly by D&A Clinical Manager and Clinical Director; the first quarterly survey of 2025 will be due in April 2025. The remaining quarterly survey due dates will be July 2025, October 2025, and January 2026. The D&A Clinical Manager and Clinical Director will review the quarterly survey data along with quarterly reports from the internal training system in order to determine number of training hours completed and any scheduled trainings for D&A staff remaining. The first date for the training review meeting will occur in April 2025. D&A Clinical Manager and Clinical Director will continually collaborate to enhance in-house training options for D&A staff by coordinating regular training opportunities in group supervision settings. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on consent to release information forms in one of seven client records reviewed.
Client #3 was admitted on October 9, 2024 and was active at the time of inspection. A release of information form with the purpose of primary care physician was signed and dated by the client on October 5, 2024; however, the consent form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
LMCMS Clinician assigned to Client #3 coordinated with client to complete new ROI on 02/05/2025. The new ROI states that this client does not have an active primary care physician and is filled out without any PHI allowed to be shared and a checkbox completed that the client refused to sign the ROI. This new ROI was uploaded into the client's chart on 02/12/2025.
D&A Clinical Manager will hold an ROI refresher training for all D&A and intake staff in March 2025. D&A Clinical Manager, in conjunction with Clinical Director and other agency clinical managers, will provide a template with required ROI elements as well as talking points to staff to use with clients when obtaining ROIs.
The LMCMS D&A Clinical Manager will conduct monthly chart audits. These audits will include the review of submitted ROIs to ensure that releases properly document the specific information to be disclosed. The D&A Clinical Manager will consult with Clinical Director on a quarterly basis to determine if any further training is needed to support staff with correct ROI completion.
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