INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 6, 2008 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 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 June 3, 2008.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of training records, the facility failed to document feedback on completed training for the 2007 training year in one of two records reviewed, #2.
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Plan of Correction
The Site Director of Jenkintown will conduct an on-site training for all staff pertaining to the completion of evaluation forms for all trainings attended. All staff members will sign off that they understand the intent of this regulation. All training evaluation forms will be kept in the Staff Development Log at the Jenkintown office & monitored monthly by the Site Director. |
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 the fire drill records and administrative documentation, the facility failed to provide documentation that the central fire alarm system was in working order pursuant to the letter of agreement with the Division dated April 2, 2008. The letter of agreement allowed the facility to utilize an alternative method for announcing fire drills so that it would not disturb the other occupants of the office building; but the program was required to have the required documentation available for review during the licensing inspection.
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Plan of Correction
The Site Director of Jenkintown will contact the building maintenance staff of the Noble Plaza and obtain proof of the yearly inspection of the central fire alarm system. A copy of the yearly inspection will be obtained from the building managment and kept in the Staff Development Log at the Jenkintown location; clearly marked in the Fire Safety section of the Log. |
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 complete treatment plan update in two of two records reviewed, #2 and 4. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
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Plan of Correction
The Site Director of Jenkintown will conduct an in-service training on treatment plan updates for all staff. Staff members will sign off that they attended this specialized training & that they understand the intent of the State regulation. The Site Director will conduct random, monthly chart audits to ensure that this problem is corrected. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document complete group progress notes in four of four client records reviewed, #1, 2, 3 and 4. The group progress notes did not include an assessment or plan from the treatment session; the group progress notes only included the general topic of the treatment session and a comment relative to each individual's response or participation in the group session.
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Plan of Correction
The Site Director of Jenkintown will conduct an in-service training for all staff regarding proper documentation of group notes using a DAP format. All staff will sign off that they attended the training & understand the state standard. The Site Director will perform monthly, random chart audits to ensure that this problem has been corrected. |