INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 13, 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 11, 2008.
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Plan of Correction
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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 staff development records, personal records, the staffing requirements facility summary report, and an interview with the facility director on March 14, 2008, the facility failed to train a sufficient number of staff in CPR and first aid to cover all facility hours of operation. A sufficient number of staff are not trained to cover evening hours, and scheduled and unscheduled leave time.
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Plan of Correction
The Site Director of Lansdale will ensure that an adequates number of staff members will attend the 3/28/2008 CPR/First Aid training being held by Cardiac Care Associates at the Center City Rehab After Work location. This will ensure that a sufficient number of Lansdale staff are trained to cover evening hours, and scheduled/unscheduled leave time. |
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 a review of client records the facility failed to establish treatment and rehabilitation plans within fourteen days of admission as required in the organizational treatment and rehabilitation procedures. Two of eight active client records reviewed on March 14, 2008 did not have documentation of individual treatment and rehabilitation plans within fourteen days of admission. Client record # 1, Admitted January 24, 2008, the treatment plan was not documented until February 20, 2008. Client record # 5, Admitted December 20, 2007, the treatment plan was not documented until January 21, 2008.
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Plan of Correction
The Site Director of Lansdale will ensure that the counselor(s) of records #1 & #5 attend a specialized training on completion of rehabilitation plans in timely fashion. Each staff member in attendance will sign off with respect to training attendance & understanding of documentation needed to comply with the state standards. The Site Director will randomly audit charts on a monthly basis until problem is "corrected". |
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 update treatment and rehabilitation plans every sixty days and did not include an assessment of the clients' progress. Three of eight active records reviewed on March 14, 2008 failed to include documentation of treatment and rehabilitation plan updates every sixty days or inclusion of a statement regarding the clients' progress or lack of progress. Client record # 2 - Admitted September 14, 2007 - A treatment plan update documented on March 2008 did not include a progress assessment. Client record # 4, Admitted August 7, 2007 - The treatment plan update was not completed within sixty days. That treatment plan update was documented in ninety days.
Client record # 5, Admitted on December 20, 2007 - There was no treatment plan update documented as of March 14, 2008.
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Plan of Correction
The Site Director of Lansdale will ensure that the counselor(s) of records #2, #4, and #5 will attend a specialized training on rehabilitation plan updates. All applicable staff will be trained on all aspects of treatment plan updates & documentation required. Each staff member will sign off on attending & understanding of the state requirements. The Site Director will randomly audit charts on a monthly basis until problem is "corrected". |