INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2-3, 2010 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 1, 2010.
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Plan of Correction
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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, 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 request within 90 days for a waiver of this regulation. If the waiver is not granted, then the executive 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 the area on a monthly basis and note progress in the gorverning body minutes (manual). |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on the review of client records, the facility failed to document a medication record in three of three client records.
The findings include:
Six client records were reviewed on March 3, 2010. Of the six records reviewed, three were currently prescribed medication. The facility was required to document the name, the dosage and the frequency of use for all medications being taken. The facility did not document the dosage and/or the frequency of use for medications in client records # 3, 4 and 6.
Client record # 3 documented the client was currently prescribed 25 mg of Paxil, but the record did not document the frequency of use for this medication.
Client record # 4 documented the client was currently prescribed Wellbutrin, but the record did not document the dosage and the frequency of use for this medication.
Client record # 6 documented the client was currently prescribed 4 mg of Adderall, but the record did not document the frequency of use for this medication.
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Plan of Correction
The site director of Paoli will conduct an in-service on all components of the medication record in the client record for all staff at the Paoli office. The site director will be responsible for ensuring the corrective actions are implemented. All Paoli staff will sign off that they attended this training and understand the intent of the state regulation. The site director of Paoli will randomly audit client records on a monthly basis to ensure the standard has been fully met. The site director will hold the in-service on Wednesday April 7,2010. Corrective action will be completed by May 7, 2010. |
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 the review of client records, the facility failed to document follow-up information in one of one client records.
The findings include:
Six client records were reviewed on March 3, 2010. Two of the six records required documentation of follow-up information. The facility did not document follow-up information within one week from the date of discharge, as per facility policy, in client record # 7.
The facility ' s policy titled " Follow- Up Information " states:
When a patient has been discharged and referred to an outside resource, the Counselor or a designee of the Site Director, with the written consent of the client and within one week from the day the referral is completed, attempts to determine from the resource and/or client the disposition of the referral. The Counselor and/or the designee of the Site Director then will document the attempt in at least one of the following areas located in the chart:
1.At bottom left section of the Record of Service - under additional notes section;
2.On right side of the Record of Service - under Notes section;
3.Or documented in the discharge summary section of the chart.
Client # 6 was admitted to the program on 7/30/09 and discharged on 12/8/09, but follow-up was not documented at the time of review on 3/3/10.
The facility director confirmed that follow-up was not documented in client record # 6.
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Plan of Correction
The site director of Paoli will conduct an in-service on all components of follow-up information for clients who are discharged from treatment for all staff at the Paoli office. The site director will be responsible for ensuring the corrective actions are implemented. All Paoli staff will sign off that they attended this training and understand the intent of the state regulation. The site director of Paoli will randomly audit client records on a monthly basis to ensure the standard has been fully met. The site director will hold the in-service on Wednesday April 7,2010. Corrective action will be completed by May 7, 2010.
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