INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 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 18, 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
In four of four staff training files reviewed the project failed to provide or document first aid training to a sufficient number of staff to assure at least one person was currently certified during the hours of operation.
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Plan of Correction
The center city site did not have current first aid training on file at the facility. The site director, Sheila will register one employee for current first aid training at a local health facility by 8/16/2007. The employee will bring proof of completed training to the site director by 8/16/2007. This certificate will be placed in facility education log located at the center city office. |
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 president of Rehab After Work stated project goals & included in the governing body minutes, but without specific goals and time frames included. Tom Whiteman, president & Susan Mackey will record specific objectives with time frames included by 6/21/2007. These will also be documented & included in the 2007 governing body report after approval from 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
A review of the organizations letters of agreement, on May 16, 2007, failed to document provisions through a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric and medical coverage.
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Plan of Correction
A current letter of agreement with a local medical/psychiatric facility was not included in the center's referral agreement log. The site director of center city will contact Thomas Jefferson Hospital representative before 6/16/2007 & send a revised letter of agreement which includes wording specific to 24 hour emergency psychiatric & medical coverage. The site director (Sheila) will monitor progress monthly & place this new document in current referral agreement log when it is recieved by the facility. |
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
In three of three discharged client records reviewed the organization failed to document a completed client record. Three of three discharged client files did not document follow-up information.
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Plan of Correction
Proof of the 7 day follow-up contact upon discharge from Rehab After Work was not found on the clinical record. The site director, Sheila, will perform an in-service training specific to "Follow-up documentation" with all staff by 8/16/2007. All staff will sign off that they understand this documentation requirement. The site director will audit random "completed" charts on a monthly basis to ensure that the standard in in compliance by 8/16/2007. |