INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 13, 2013 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:
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Plan of Correction
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of the facility's administrative documentation, the facility failed to provide verification of a written agreement with a licensed hospital or physician, for 24 hour emergency medical and psychiatric coverage.
The findings include:
The administrative documents were reviewed at the project's corporate headquarters on March 5, 2013, and again at the facility on March 13, 2013. The project was unable to provide a written agreement with a licensed hospital or physician for 24 hour emergency medical and psychiatric coverage, as required.
An interview with the site director confirmed the facility did not secure a contract for emergency medical coverage.
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Plan of Correction
The Site Director of York will obtain in writing a contract/administrative documentation with hospital, physician, 24-hour emergency medical, or psychiatric coverage by date of 5/1/2013. This contract will be held in York office as well as a copy will be housed in the main Human Resources office of Rehab After Work. The steps the facility will take to ensure this deficiency will not occur again is that within the written agreement request will be explicitly stated that the agreement between Rehab After Work and referral agency will remain good and can only be cancelled with written consent from both parties. This will ensure ongoing contractual obligation to provide emergency medical, psychiatric assistance referral movign forward. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to permit a client to have the opportunity to request reconsideration of the decision to terminate treatment in two of two client records.
The findings include:
Two client records were reviewed for termination letters on March 13, 2013. Two of two client records reviewed failed to inform clients of their right to appeal a decision to terminate treatment, specifically records # 4 and 5.
Client # 4 was admitted to the program on October 14, 2012 and was involuntarily terminated from the program on December 10, 2012. The facility did not provide the patient the opportunity to request reconsideration of the decision to terminate treatment.
Client # 5 was admitted to the program on October 4, 2012 and was involuntarily terminated from the program on November 5, 2012. The facility did not provide the patient the opportunity to request reconsideration of the decision to terminate treatment.
The finding was confirmed by the site director on March 13, 2013.
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Plan of Correction
The Site Director of the York office will change the termination letter so that included in the body of the letter the client will have written that he or she will have permission to request reconsideration fo the decision to termiante treatment. This change will occur immediately upon this writing. This new termination letter will be written in accordance with State Policy 709.33. The Site Director will follow through with each clinician with an inservice by 4/10/13, on the termination process including the written and oral aspects of alerting clients of their ability to reconsider the decision to terminate treatment. Both charts audtited will also have the termiantion letter addressed and corrected with new corrected letters sent out to clients. Each clinician will sign that they understand the documentation procedure and intend to comply. The Site Director will conduct random, monthly chart audits to ensure compliance. |