INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10, 2017 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 to be not 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection conducted on April 10, 2017, the facility failed to have the fire extinguishers inspected annually.
Fire extinguisher in the hallway next to the chart room had an inspection tag from September 2015.
Fire extinguisher in waiting area did not have any inspection tag at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Fire Equipment Company was contacted to inspect and replace tags on all fire extinguishers in the hallway and waiting area on 4/21/17. They have now been scheduled to come annually to inspect all fire extinguishers to remain in compliance. |
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.
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Observations
Seven client records were reviewed on April 10, 2017. The facility failed to obtain a valid consent to release information in client records, #1 and 7.
Client #1 was admitted on 9/23/16 and was an active client at the time of the licensing inspection. A consent to release to a family member dated 9/23/16 did not have the purpose for the release of information identified.
Client #7 was admitted on 9/9/16 and was discharged on 1/12/17. A consent to release to an employer dated 9/9/16 permitted the release of the client's prognosis, nature of the program, progress in treatment, and attendance which exceeds 4 PA. Code 255.5.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The identified consent that was out of compliance was revised and replaced with the client on 4/11/17. Supervisor conducted a training on Confidentiality with staff on 4/13/17 and reviewed proper documentation of consents and limitations of releases. Supervisor will review proper documentation and use of consents during staff supervision 1x month and conduct monthly chart audits to ensure compliance. |
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
Seven client records were reviewed on April 10, 2017. The facility failed to document a psychosocial evaluation that included the counselor's documented evaluative statement and recommendations in records, #1, 4 & 5.
Client #1 was admitted on 9/23/16 and was an active client at the time of the licensing inspection. Psychosocial evaluation dated 9/23/16.
Client #4 was admitted on 7/1/16 and was discharged on 10/10/16. Psychosocial evaluation dated 7/7/16.
Client #5 was admitted on 8/15/16 and was discharged on 12/2/16. Psychosocial evaluation dated 8/15/16.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Supervisor conducted a training during staff meeting on 4/13/17 and reviewed evaluative statements and recommendations that will be included in psycho social assessments. Staff was asked to practice this skill during staff meetings to demonstrate competence in developing evaluative statements and recommendations. Supervisor will review proper documentation of clinical evaluations and recommendations 1x month. Supervisor will conduct monthly chart audits to ensure compliance and proper documentation. |