INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5-6, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, Inc - Vandergrift 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 October 4, 2007.
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Plan of Correction
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of the fire drill log on September 5, 2007 at 10:15 am. and the interview with the project director on September 5, 2007, it was determined that the facility failed to document the fire alarm and smoke detector were operative at the time of the fire drills.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on client record reviews on September 6, 2007, it was determined that the facility failed to provide complete lengths and patters of substance abuse, missing the progression of drug and alcohol use in the drug and alcohol history. Three of five client records do not include this documentation. Client records # 2, 3, and 5.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of the client records on September 6, 2007, the facility failed to provide complete individual treatment plans for the clients. The objectives and/or interventions listed do not provide specific action steps for the goals on the treatment plans. Three of five client records, #2, 4 and 5, were missing the action steps.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Based on the review of client records reviewed on September 6, 2007, it was determined that the facility failed to provide the frequency of treatment on the treatment plans. Three of five client records, #1, 2, and 5, contained treatment plans that were missing the frequency of treatment.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 a review of the client records on September 6, 2007, it was determined that the facility failed to provide the reason for treatment, services offered to the patient, and the patients response to treatment on the discharge summaries in client records # 4 and 5.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |