INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21, 2008 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 and a plan of correction is due on April 18, 2008.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the staffing requirements facility summary report the facility failed to provide for all mandatory training within the specified time period. The counselor in position number two on page three of the staffing requirements facility summary report, completed and reviewed on March 21, 2008, did not obtain four hours of TB/STD and other health related issues within one year of employment. The staff person was hired on September 2004 with no documented TB/STD training as of March 21, 2008.
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Plan of Correction
The Site Director of Havertown will require the counselor in question to produce proof of 4 hours TB/STD training. The Site Director will monitor counselor's progress with obtaining required 4 hours of documented TB/STD training. Monthly progress reports will be placed in Staff Development log until the Counselor produces proof of this training. If this standard is not met, the counselor will face disciplinary action outlined in Rehab After Work's Human Resource Manual. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of training and staff development records, an interview with the facility director on March 21, 2008, and a review of the staffing requirements facility summary report the project failed to have at least one person trained in first aid. No staff are trained in First Aid.
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Plan of Correction
The Site Director of Havertown will ensure that at least two staff members attend the 3/28/2008 CPR/First Aid training held by Cardiac Care Associates at the Center City Rehab After Work location. Proof of the training & proof of staff attendance will be placed in the Havertown Staff Development manual by the Site Director. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Two of seven client records reviewed on March 21, 2008 did not have complete consents to disclose information. Two records reviewed did not have the specific information or purpose of disclosure completed, however, client and witness signatures were completed and dated.
Client record # 1 - Admitted December 12, 2007 . Signatures were included on the consent to release information forms, but the signed forms did not include the completed purpose and specific information sections.
Client record # 5 - Admitted December 8, 2007 and discharged July 30, 2007. The purpose and specific information sections were not completed, but the clients signature and the signature of a witness were on the form.
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Plan of Correction
The Site Director of Havertown will require that counselor(s) of client records #1 & #5 attend a specialized training in procedures regarding informed and voluntary consent of client releases. The counselor(s) will sign off that they attended this training and understand the state standard. The Site Director will conduct random, monthly chart audits until the problem is "corrected". |
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 include documentation of follow-up information.
Two of three discharged client records reviewed on March 21, 2008 did not include documentation of follow-up information within one week of discharge. Organizational treatment management procedures and established follow-up policy requires follow-up services within one week of discharge.
Client record review # 5 - Admitted December 8, 2006, discharged July 30, 2007 without follow-up documentation.
Client record review # 7 - Admitted May 7, 2007, discharged September 20, 2007 without follow-up documentation.
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Plan of Correction
The Site Director of Havertown wil require that counselor(s) of client records #5 & #7 attend a specialized training on documentation of follow-up information. The staff will sign off that they attended the training and understand the intent of this state/facility standard. The Site Director will conduct monthly, random chart audits to ensure that this problem has been "corrected". |