INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 20, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab Management Inc. 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on observations on February 20, 2014, the facility failed to ventilate bathrooms by exhaust fan or window in two of two bathrooms.
The findings include:
A physical plant inspection was conducted on February 20, 2014, 1 men's public restroom and 1 women's public restroom were inspection. The following restrooms were not ventilated by an exhaust fan or window:
1)The men's public restroom at approximately 10:04 A.M.
2)The women's public restroom at approximately 10:05 A.M.
The findings were confirmed during an interview with the facility director on February 20, 2014 at approximately 10:06 A.M.
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Plan of Correction
THE MENS PUBLIC RESTROOM AND WOMENS PUBLIC RESTROOM WERE CORRECTED THE EVEING OF 2/20/14 AND OUR NOW VENTILATED BY EXHAUST FANS. THE SITE DIRECTOR WILL CHECK EXHAUST FANS WEEKLY TO INSURE WORKING PROPERLY. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the project failed to notify the client in writing of a decision to involuntarily terminate the client's treatment at the project in one of one client record reviewed.
The findings include:
On February 20, 2013, one client record requiring documentation that the project notified the client in writing of a decision to involuntarily terminate the client at the project was reviewed. The project failed to notify the client in writing of a decision to involuntarily terminate the client's treatment at the project in one of one record reviewed, specifically client record # 10.
Client # 10 was admitted September 30, 2013 and involuntarily terminated November 18, 2013. However, client record # 10 did not include documentation of a decision to involuntarily terminate client # 10 from the project as of February 20, 2013.
The findings were confirmed during an interview with the facility director on February 20, 2014 at approximately 3:00 P.M.
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Plan of Correction
THE SITE DIRECTOR WILL TRAIN ALL CLINICIANS ON THE DISCHARGE PROCEDURE, POLICIES AND STATE REGULATIONS. THE TRAINING WILL TAKE PLACE ON 4/1/14. WRITTEN DOCUMENTATION OF INVOLENTARY DISCHARGE WILL BE RECORDED AND GIVEN TO THE CLIENT OR MAILED TO THE CLIENT TO INFORM OF THIS DECISION. THIS WAS CLIENT #10 CHART. THE SITE DIRECTOR WILL BE RESPONSIBLE FOR CHECKING IN WITH STAFF IN CLINICAL SUPERVISION ON THEIR STATUS OF CORRECTING THIS MISTAKE AND WILL REVIEW LETTERS SENT TO INVOLUNTARY DISCHARGED CLIENTS WHEN DOING CHART AUDITS QUARTERLY. |
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 a review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in four of ten client records reviewed.
The findings include:
On February 20, 2014, ten client records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in four of ten records reviewed, specifically, client records # 2, 6, 8, and 9.
Client # 2 was admitted October 15, 2013. The individual treatment and rehabilitation plan was completed October 25, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of February 20, 2014.
Client # 6 was admitted October 17, 2013. The individual treatment and rehabilitation plan was completed October 23, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of February 20, 2014.
Client # 8 was admitted October 17, 2013 and discharged December 2, 2013. The individual treatment and rehabilitation plan was completed November 14, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of February 20, 2014.
Client # 9 was admitted September 23, 2013 and discharged October 23, 2013. The individual treatment and rehabilitation plan was completed September 24, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of February 20, 2014.
The findings were confirmed during an interview with the facility director on February 20, 2014 at approximately 3:00 P.M.
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Plan of Correction
THE SITE DIRECTOR WILL HAVE A TRAINING ON MASTER TREATMENT PLANS AND TREATMENT PLAN UPDATES. THE TRAINING WILL TAKE PLACE ON 4/1/14 AND WILL DISCUSS THAT AT LEAST ONE RECOMMENDATION THAT A SUPPORT SERVICE IS OFFERED IN THE DEVELOPMENT OF THE TREATMENT PLAN. THE STATE REGULATIONS WILL BE REVIEWD AND REHAB AFTER WORKS POLICIES AND PROCEDURES ON TREATMENT PLANS. THE SITE DIRECTOR WILL REVIEW THROUGH CHART AUDITS ON A QUARTERLY BASIS TO ENSURE THAT SUPPORT SERVICES ARE BEING RECCOMENDED IN THE TREATMENT PLAN. |