INITIAL COMMENTS
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This report is a result of a on-site follow-up inspection regarding the plans of correction for the February 28, 2011 licensure renewal inspection.
The follow-up inspection was conducted on August 11, 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:
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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 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.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document fire extinguisher training upon staff employment.
The findings include:
Two personnel records were reviewed on February 11, 2011 to verify that staff had been instructed in the use of a fire extinguisher upon employment.
The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record # 2.
Employee # 2 was hired March 25, 2010.
The training was due upon employment, the training was documented on April 5, 2010.
This was still out of compliance at the time of the follow-up inspection conducted on August 11, 2011.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
Two personnel records were reviewed on February 11, 2011 to verify that staff had been trained to perform assigned tasks during emergencies.
The facility failed to ensure that personnel on all shifts were trained to perform assigned tasks during emergencies.
Employee # 2 was hired March 25, 2010.
The training was not documented until April 5, 2010.
This was still out of compliance at the time of the follow-up inspection conducted on August 11, 2011.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 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 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.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |