INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the initial licensure inspection conducted on April 1, 2010 . The follow-up inspection was conducted on December 28, 2010 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 and a plan of correction is due on January 25, 2011.
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Plan of Correction
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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on observation when entering the facility and an interview with the counselor, the facility failed to have the trash cans covered to prevent the penetration of insects and rodents.
The findings include:
On December 28, 2010, at 9:00 a.m., three trash cans were observed on the left side of the building. Two of the cans did not have lids to cover them. The third trash can had a lid, however, it was not being used at the time of the inspection. An interview was conducted with the counselor and he was made aware of the regulation and confirmed that the trash cans did not have covers on them.
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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) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill logs and an interview with the counselor, the facility failed to maintain a written fire drill record that included the time, the exit route used, problems encountered and whether or not the fire alarm or smoke detector was operative, as required.
The findings include:
Fire drill logs were reviewed on December 28, 2010. Per regulation, the nonresidential facility shall maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. The facility failed to document the time, the exit route used, problems encountered and whether or not the fire alarm or smoke detector was operative, as required in nine of nine drills conducted.
On December 28, 2010, the counselor was interviewed and confirmed that the aforementioned areas had not been documented on nine of the nine fire drills conducted.
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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) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on December 28, 2010. The facility did not document any alternate exit used during fire drills.
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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) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill logs, the facility failed to document fire drills during different times of the day and on different staffing shifts.
The findings include:
The fire drill logs were reviewed on December 28, 2 010. The documentation failed to include the time of day the drill took place. Therefore, there was no way to determine whether or not the fire drills were conducted during different times of the day and on different staffing shifts.
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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) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs and an interview with the counselor, the facility failed to activate a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on December 28, 2010. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The fire drill log was reviewed for documentation of fire drills from the time period of April 2010 to December 2010. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been activated for every fire drill documented.
The counselor was interviewed on December 28, 2010, and confirmed the fire alarm or smoke detector was not activated each month.
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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. |
709.24(a)(1) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(1) Defined target population.
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Observations
Based on review of the policy and procedure manual and an interview with the Counselor, the facility failed to include the target population for the geographic area where the program is located.
The findings include:
The policy and procedure manual was reviewed on December 28, 2010. The target population defined in the policy and procedure manual did not include the area where this facility is located. The policy only included residents of the five counties of the greater Philadelphia area and Southern New Jersey. The policy failed to include residents of York County.
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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. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on the review of client records and an interview with the counselor, the facility failed to document support services on two of three client records reviewed.
The findings include:
Three client records were reviewed on December 28, 2010 and were reviewed for documentation of proposed support services on the client's treatment plan. Client records
# 2 and 3 failed to include documentation of proposed support services on the comprehensive treatment plan.
An interview with the counselor confirmed that the support services were not present in the treatment plans.
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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. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update in one of one client record, where required.
The findings include:
Three client records were reviewed on December 28, 2010. One client record was required to have a treatment plan update. Per the facility policy, treatment plan updates are required to be completed every 60 days. The facility failed to document a treatment plan update in client record #1.
Record #1 - The client was admitted on May 17, 2010. The comprehensive treatment plan was completed on May 7, 2010. A treatment plan update was due by July 7, 2010. The client was discharged on July 28, 2010. The facility failed to document the completion of a treatment plan update in this client record.
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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. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up attempts in two of two discharge records.
The findings include:
Three client records were reviewed on December 28, 2010. Two of the three client records were discharged clients and required documented follow-up attempts. Follow up was not documented in client records #1 and 2.
Record # 1 was admitted on 5-7-10 and discharged on 7-28-10. The follow up attempt was due on 8-4-10. As of the date of the inspection no follow-up documentation was recorded in the client record.
Record # 2 was admitted on 10-4-10 and discharged on 10-11-10. The follow up attempt was due on 10-18-10. As of the date of the inspection no follow-up documentation was recorded in the client record.
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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. |