INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 22, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on June 22, 2007.
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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
The project failed to provide training or provide documentation that a sufficient number of staff were trained in CPR and First aid so that at least one person is onsite during the hours of operation.
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Plan of Correction
There was no documentation of current CPR & First Aid trainings. The site director will encourage at least one other staff member to enroll in these trainings by 8/22/2007 - offered at local YMCA and/or local medical facility. Two staff at Exton will produce proof of current certification & this documentation will be placed in personel file at the Exton location. The site director will monitor progress of corrective action on a monthly basis until completed. |
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
The facility failed to document fire extinguisher training in one of two personnel files reviewed. File number 2.
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Plan of Correction
One employee did not have documentation of fire extinguisher instruction completed & placed in their personel files within 7 days of hire date. The site director of Exton will orient employee #2 on "How to use fire extinguishers at the site" & have employee #2 sign off that this instruction is completed by 7/15/07. Documentation will be placed in their personel files by the site director. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to document emergency fire safety training in one of two personnel files reviewed on May 22, 2007. File number 2.
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Plan of Correction
One employee did not have proof of training completed on emergency training & evacuation protocol. The site director will meet with employee #2 & review emergency protocol & evacuation procedures contained in our site manual. The employee will sign off on training when completed & this documentation will be placed on personel file by 7/15/2007 by the site director. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The project director failed to establish project goals and objectives with time frames and available resources. A review of governing body information, to include board meeting minutes and quarterly reports, failed to include the necessary documentation.
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Plan of Correction
The presidentof Rehab After Work stated project goals and included these in the governing body minutes, but without specific goals and time frames included in the report. the project director with help from the administrative manager, will write down the specific objectives with quarterly time frames reported/included by 6/21/2007. These will be documented & included in the 2007 Governing Body report after approval from the Governing Body by 6/30/2007. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
The facility failed to document an agreement for 24 hour emergency medical and psychiatric coverage after a full review of the organization's treatment management plan and letters of agreement.
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Plan of Correction
A current 24 hour medical emergency & psychiatric referral agreement letter was not located at the Exton site the day of the inspection. This letter was sent out prior to site visit, but had not been returned by Chester County Hospital/Chester County Crisis Center. The site director will ensure that a current, updated letter of agreement will be forwarded to the Exton office & placed in the referral agreement log at the Exton site by 8/22/2007. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
The project failed to provide documentation of efforts toward informing employee number 2 of employee rights.
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Plan of Correction
Employee rights are included during the orientation period and placed in personel files. One file at Exton office did not include this documentation. The site director of Exton will meet with the employee affected; review employee rights stated in our manual; and have the employee sign off that this was completed. This documentation will be placed in their personel files by 7/30/2007. |
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
The facility failed to document complete consent to release information forms in client records #1, 3 and 4. The facility failed to ensure that those consent to release information forms were consistently signed in the three client records identified.
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Plan of Correction
Three files audited at the Exton office did not have proper release information completed during time of site visit. The site director will conduct a staff training by 7/30/2007 for all Exton staff members. The training will encompass proper documentation of all releases completed at RAW locations. Exton staff members will sign off that they understand the standard regarding release information. The site director will randomly audit charts on a monthly basis until the site is in full compliance. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The facility failed to provide for a complete personal history in client record #4.
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Plan of Correction
One chart at the Exton office did not contain a fully completed personal history. The site director will conduct an in-service training regarding intake and completion of personal history sections. All Exton staff members will participate in the training & sign off that they understand the intent of the standard. The site director will perform monthly audits on random records until the site is in complete compliance with the standard. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
A review of five client records revealed the lack of type and frequency of treatment on the individualized treatment plan in client records # 3 and 5.
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Plan of Correction
Two clinical records did not have boxes checked off in the Treatment Plan that indicated the type & frequency of treatment offered to the individual. The site director will conduct a training on Treatment Planning for all Exton staff. The staff will participate in the training & demonstrate a clear understanding of the standard regarding treatment planning. The site director will pull random charts on a monthly basis to ensure that the standard is being met at the Exton office. |
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
The facility failed to document medication dosage and the frequency of use of medication in client records # 1 and 4.
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Plan of Correction
Two charts did not contain medication information regarding dose & frequency. The site director of Exton will conduct a staff training on "Documentation of Medication" in this section of the client record by 8/15/2007. All staff will participate in this training and sign off that they understand the standard involving medication records. The site director will conduct monthly, random chart audits until the standard has been clearly met at the Exton office. |
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
The facility failed to document the required aftercare plan in client record #8.
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Plan of Correction
One client record did not contain an aftercare plan. The site director will conduct a staff training on "Aftercare Planning" for the Exton center by 8/22/2007. All Exton staff will participate in the training and sign off that they understand how to document to meet the standard. The site director will complete random, monthly chart audits to ensure that the center is in full compliance with this standard. |
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
The facility failed to document follow up attempts in client records # 6, 8 and 9.
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Plan of Correction
Three records did not show documentation of a seven day follow-up attempt. The site director of Exton will conduct a staff training on "How to document follow-up attempts in the Client Record". All Exton staff will attend the training & sign off that they understand the standard. The site director will perform random, monthly chart audits until the center is in full compliance. |