INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 2, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted on April 2, 2018 at approximately 2:45 pm, the facility's women's bathroom had a hot water temperature that was measured at 136.4 degrees. Additionally, the women ' s bathroom was not maintained in a functional, clean, and sanitary manner as the third stall from the left had a toilet that was non-functional, unclean, and filled with human waste.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor and program director reached out to the property owner and building management on 4/2 to notify them of the issues noted. Building management will ensure that the water temperature of the sink is returned to proper temperature, and that the toilet third from the left is able to flush properly. The clinical supervisor ensured that the stall door was locked and that a sign was posted to notify clients that it was not usable; as well as to notify clients about the hot water. Program Coordinator will be in contact with building management about on going cleaning needed of the bathroom. Clinical supervisor will continue to check the bathroom functioning and water temperature on a monthly basis. |
709.92(a) 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:
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Observations
Based on a review of 7 client records, 3 client records failed to contain documentation of comprehensive treatment plans.Client #1 was admitted on 12/14/17 and was active at the time of inspection. Client #2 was admitted on 12/29/17 and was active at the time of inspectionClient #3 was admitted on 1/17/18 and was active at the time of inspectionThese findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will require that all clinicians be trained on the correct treatment plan procedures and how to enter correctly into carelogic. The training for these procedures will take place on 4/17. The clinical supervisor will be responsible for checking in with staff in clinical supervision on the status of their correcting this mistake going forward. The supervisor will perform random, monthly charts audits to ensure that this policy change is being reflected by all clinicians. |