INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection to the initial onsite licensure inspection conducted on March 2, 2010 by staff from the Division of Drug and Alcohol Program Licensure. The follow-up inspection was conducted on August 13, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 September 20, 2010.
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Plan of Correction
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
This deficiency can not be re-evaluated until the next licensing inspection.The facility did not have any newly hired employees to review for the fire extinguisher training at the follow-up inspection that was conducted on August 13, 2010. Please resubmit the original plan of correction date for the date of completion.
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Plan of Correction
The Site Director of Exton will begin training immediately. All new hires from this point forth will be trained on fire extinguisher use within 7 days of being hired, and will be documented properly. In regards to current employees a training will be held to update training from January 2010. All exton staff are required to attend and sign off that they understand the intent of this standard. |
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 an interview with the Facility 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:Documentation of an annual audit of financial activities was requested during the onsite follow-up inspection conducted on August 13, 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 Facility Director was not able to present an independent annual audit of financial activities; nor did he know if the project had obtained the services of an independent public accountant for an annual audit.
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Plan of Correction
The Executive Director submitted exemption letter 8/27/2010. If exemption is not granted, Rehab After Work will hire an outside CPA to conduct an independent audit for fiscal years 2008 and 2009 within 90 days. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document treatment plans to include proposed type of support services.The findings include:Five client records were reviewed on August 13, 2010. All five client records were required to include documentation of a treatment plan with support services. The facility failed to document a treatment plan to include proposed types of supportive services in client records # 4 and 5.The facility's policy on Comprehensive Treatment Plan states:The Comprehensive Treatment Plan is an individual treatment and rehabilitation plan developed in collaboration with each patient and their assigned Primary Counselor. This plan shall include, but not be limited to, written documentation of:1. Short and long term goals for treatment as formulated by both the Primary Counselor and the patient. Goals should be realistic and stated in terms of measurable criteria.2. Type and frequency of treatment and rehabilitation services.3. Proposed type of support service. Services may include medical, psychiatric or mental health services, financial, legal, AA, NA, etc.In record # 4, the treatment plan documented on 7/14/10 did not contain a statement of the type of support services provided or arranged for the patient.In record # 5, the treatment plan documented on 6/18/10 did not contain a statement of the type of support services provided or arranged for the patient.
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Plan of Correction
The site director of the Exton office will begin training immediately, on how to properly create, and document treatment plans for client charts. Specifically charts #4 &5, as well as all others. Specifically in reference to documenting in treatment plan specific support services including AA, NA, legal, spiritual, etc. This will be held on 10/15/10 and all the staff at the Exton office are mandated to attend and sign off that they understand. The site director will conduct random chart audits until the site is in full compliance. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records during the initial inspection of March 24, 2010, the facility failed to document a complete client record which included an aftercare plan in three of seven client records where required.The findings include:Seven client records were reviewed on March 24, 2010. An aftercare plan was required in three client records. The facility failed to document an aftercare plan in client records # 6 and 7 within one month of the scheduled discharge date, as per facility policy.The facility's policy titled " Continuing Care Plan" states:The final phase of treatment is aftercare planning. In accordance with a relapse prevention philosophy, RAW policy requires that patients develop an effective detailed plan for maintenance of sobriety after completing the program. The primary counselor is responsible for meeting with the patient to develop a detailed continuing care plan for the patient to follow after they leave formal treatment. The continuing care plan is completed within one month of the scheduled discharge date in the context of ongoing individual counseling sessions. The continuing care plan is completed and signed by the patient and counselor before anticipated discharge. Client #6 was admitted to the program on 12/18/09 and discharged on 1/20/10, aftercare was not documented at the time of review on 3/24/10.Client #7 was admitted to the program on 1/20/10 and discharged on 2/24/10, aftercare was not documented at the time of review on 3/24/10.The facility did not have any clients that could be reviewed for an aftercare plan at the follow-up inspection that was conducted on August 13, 2010. Please resubmit the original plan of correction date for the date of completion.
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Plan of Correction
The site director of Exton will begin training immediately. An inservice on the proper way to document discharge paperwork will be scheduled for 4/19/2010 as well as 10/15/2010. All staff at Exton site are mandated to attend and sign off that they understand the intent of the standard as well as the parameters of the standard. the site director will conduct random chart audits of closed charts until the office is in full compliance. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on the review of client records on March 24, 2010, the facility failed to document a complete client record which included a discharge summary in two of seven client records.The findings included:Seven client records were reviewed on March 24, 2010. Five of seven records required documentation of a discharge summary. The facility failed to document a discharge summary in client records #6 and 7.The facility's policy titled "Discharge Documentation" states:Clients choose to leave treatment at different points during their treatment episodes. Some people remain in treatment until they have successfully completed treatment where as other individuals leave treatment Against Medical Advise. Despite the point in time that a person leaves treatment appropriate documentation of their discharge is required. Within seven days of discharge from the program, a discharge summary is entered in the record.Client #6 was admitted to the program on 12/18/09 and discharged on 1/20/10, but a discharge summary was not documented at the time of review on 3/24/10.Client #7 was admitted to the program on 1/20/10 and discharged on 2/24/10, but a discharge summary was not documented at the time of review on 3/24/10.The facility did not have any discharged clients that could be reviewed for a discharge summary at the time of the follow-up inspection that was conducted on August 13, 2010. Please resubmit the original plan of correction date for the date of completion.
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Plan of Correction
The Site director of Exton office will begin training immediately. An inservice on the proper wayt to document discharge paperwork will be scheduled for 4/19/2010. All staff at Exton site are mandated t oattend the inservice, and sign off that they understand the intent of the standard as well as the parameters of the standard. The site director will conduct random chart audits of closed charts until the office is in full compliance. |
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 on March 24, 2010, the facility failed to document follow-up information in four of five client records.The findings include:Seven client records were reviewed on March 24, 2010. Five of the seven records required documentation of follow-up information. The facility failed to document follow-up within one week from the date of discharge, as per facility policy in client records # 3, 4, 6, and 7.The facility's policy titled "Follow-up Information" state: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 designee of the site director then will document the attempt in at least one of the following areas located on the chart:1. At bottom left section of the Record of Service - under additional notes section2. On right side of the Record of Service - under notes column 3. Or documented in the discharge summary section of the chart.Client record #3 was admitted to the program on 9/29/09 and discharged on 2/10/10, but follow-up was not documented at the time of review on 3/24/10.Client # 4 was admitted to the program on 10/28/09 and discharged on 2/3/20, but follow-up was not documented at the time of review on 3/24/10.Client # 6 was admitted to the program on 12/18/09 and discharged on 1/20/10, but follow-up was not documented at the time of review on 3/24/10. Client # 7 was admitted to the program on 1/20/10 and discharged on 2/24/20, but follow-up was not documented at the time of review on 3/24/10.The facility did not have any client records that could be reviewed for documentation of follow-up information at the time of the follow up inspection that was conducted on August 13, 2010. Please resubmit the original plan of correction date for the date of completion.
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Plan of Correction
The Site director of the Exton office will begin training immediately. An inservice on the proper way to administer and document follow-up information at time of discharge within one week of discharge will be held on 4/26/2010. All staff of Exton office are mandated to attend and sign off that they understand the standard. The site director will conduct random monthly chart audits until the site is in full compliance. |