INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 22, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab Management Inc./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 April 15, 2010.
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Plan of Correction
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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 the review of the facility ' s fire drill log, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
The facility ' s fire drill log was reviewed on March 22, 2010. From January 2009 to February 2010, the facility documented " Staircase #1 " as the only exit route used during fire drills.
The facility director confirmed that " Staircase #1 " was the only exit route used during fire drills.
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Plan of Correction
The facility director will prepare alternate exit routes to be used by the facility during fire drills. Staircase #1 and staicase #2 will be used on alternative months and documented on the facility's fire drill log as such. The facility director will confirm and coordinate the use of alternate exit routes with the administrative assistant for documentation. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of administrative documentation and an interview with the project director, the facility failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility ' s administrative documentation was reviewed and an interview with the project director was conducted on March 2, 2010. The facility was required to document an annual audit of financial activities. The facility did not document a financial audit for the 2008-2009 fiscal year.
The project director confirmed that a financial audit had not been completed.
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Plan of Correction
The executive Director shall submit a written waiver of this regulation. If the waiver is not granted then the executuve director of Rehab After Work will begin the process of arranging for an independent external audit with approval from the Governing body president. The executive director will monitor progress in this area on a monthly basis and note progress in the governing body minutes(manual). |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in three of six client records.
The findings include:
Six client records were reviewed on March 22, 2010. All six records required documentation of a psychosocial evaluation. The facility did not document a psychosocial evaluation to include a complete composite description of the client, as per facility policy, in client records # 1, 4 and 6.
The facility ' s policy titled " Psychosocial Evaluation: Narrative Summary Evaluation " states:
Within 14 days of the date of admission, the primary Counselor completes a written Biopsychosocial Assessment which yields a complete composite description of the patient in relation to the collected information. The summary includes the Counselor ' s impressions, conclusions, observations, and interpretations of historical and other pertinent data.
The psychosocial evaluation in client record # 1, dated 10/12/09, contained problems and needs that were identical to the problems and needs identified on the psychosocial evaluation in client record # 4, dated 10/21/09, and also on the psychosocial evaluation in client record # 6, dated 10/6/09.
The psychosocial evaluation in client record # 1, dated 10/12/09, contained support systems that were identical to the support systems identified on the psychosocial evaluation in client record # 4, dated 10/21/09, and also on the psychosocial evaluation in client record # 6, dated 10/6/09.
Additionally, the psychosocial evaluations documented in client records # 2, 3, 4, 5 and 6 did not include the client ' s preferred coping mechanisms.
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Plan of Correction
The site director of the center city office will have an inservice training with all clinical staff on Psychosocial evalutions ny 4/28/10. All staff will sign off that they attended the training and understand the intent of this documention. The site director will do random monthly chart audits until the center is in full compliance |
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 the review of client records, the facility failed to document an individual treatment plan in five of six client records.
The findings include:
Six client records were reviewed on March 22, 2010. All six records required documentation of an individual treatment plan. The facility did not document an individual treatment plan based on the individual ' s problem and situation, as per facility policy, in client records # 1, 2, 3, 5 and 6.
The facility ' s policy titled " Treatment and Rehabilitation Plan " states:
The Comprehensive Treatment Plan must include a minimum of three key problem areas with defined goals. For each treatment goal, the plan must specify at least three objectives (that is, readily observable or measurable ways to reach the goal) and the time frame for achieving the goal. In most cases, two key goals are abstinence and sober supports. Other goals depend on the individual ' s problem and situation, and may include treatment for anxiety, depression, marital stress, employment problems, parenting problems and so forth. The goals are developed in collaboration between patient and counselor and signed by the counselor.
The treatment plan in client record # 1, dated 10/13/09, contained goals and objectives that were nearly identical to the goals and objectives identified on the treatment plan in client record # 3, dated 10/26/09, and also on the treatment plan in client record # 6, dated 10/6/09.
The treatment plan in client record # 2, dated 6/10/09, contained goals and objectives that were nearly identical to the goals and objectives identified on the treatment plan in client record # 5, dated 12/14/09.
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Plan of Correction
The site director of center city will have an inservice training with all the clinical staff on Individual Treatment Plans by 4/28/10. All staff will sign off that they attended the training and understand the intent of this documentation. The site director will perform random monthly chart audits until the center is in full compliance |