INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24, 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 24, 2010.
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Plan of Correction
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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to store all trash, garbage and rubbish in covered containers.
The findings include:
A tour of the facility ' s physical plant was conducted on March 24, 2010 at approximately 1:30 PM. The facility was required to store all trash, garbage and rubbish in covered containers. At the time of inspection, four bags of trash were on the floor in the main hallway of the facility.
The facility director reported their practice is to leave the trash in the hallway, and the building maintenance employees remove it daily.
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Plan of Correction
The facility director will address the staff habit of putting rubbish into a side hallway for collection and will abolish this policy in favor of a new policy of putting having staff members take rubbish to the dumpster outside and to the back of the building. This dumpster is a large metal storage unit and completely sealed with secure plastic lids. This will be addressed on a staff meeting on April 15th. The facility director will do regular checks to make sure that no rubbish is being disposed of in the hallway and will reinforce this policy in staff meetings on a weekly basis until compliance is 100%. |
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 and an interview with the project 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:
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 waiver of this regulation. If this 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 this area on a monthly basis and note progress in the Governing Body minutes (manual). |
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 the review of client records, the facility failed to document a treatment plan update in four of seven client records reviewed.
The findings include:
Seven client records were reviewed on March 25, 2010. All seven records required documentation of a treatment plan update. The facility did not document a treatment plan update to include an assessment of the patient ' s progress, as per facility policy, in records # 1, 3, 5 and 7.
The facility's policy titled " Treatment Plan Review and Update " states:
1.The Comprehensive Treatment Plan shall be reviewed and updated at least every 60 days.
2.The Comprehensive Treatment Plan review and update should include an assessment of the patient's progress in relationship to the stated goals of the plan
In client record # 1, the treatment plan was documented on 10/29/09, but the treatment plan updates documented on 12/3/09 and 2/4/10 did not include an assessment of progress.
In client record # 3, the treatment plan was documented on 9/21/09, but the treatment plan updates documented on 11/18/09 and 1/18/10 did not include an assessment of progress.
In client record # 5, the treatment plan was documented on 12/15/09, but the treatment plan update documented on 2/9/10 did not include an assessment of progress.
In client record # 7, the treatment plan was documented on 12/16/09, but the treatment plan update documented on 2/16/10 did not include an assessment of progress.
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Plan of Correction
The facility director will hold an inservice training addressing the need to document the assessment of progress on the treatment plan update. This training will be held on 6/24/10.
The facility director will do bi-monthly chart reviews to determine that the treatment plan updates are including an assessment of progress. The facility director will reinforce this policy in staff meetings and educate staff as needed to make sure that this policy is being followed. |