This report is a result of an on-site licensure renewal inspection conducted on August 27, 2007 through August 28, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Rehabilitation Services, 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 October 2, 2007.
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Plan of Correction
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Observations
Based on a review of client records it was determined that the facility failed to obtain physical examinations within the timelines identified in agency policy (48 hours to seven days). Client record numbers 1, 2, 3, and 5 had physical examinations dated beyond the seventh day after admission. Also, client record number 4 had documented a physical examination at the time of intake, however the content of the examination failed to include vital signs, general appearance, and the physicians impressions.
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Plan of Correction
We are developing a system to schedule physical exams and changing primary care physicians prior to a client's entry, to insure that the client receives a physical examination within seven days of entry. This effort will target two counties that have been problematic in this regard. The program director will coordinate with the program assistant to ensure that prospective clients are identified as early as possible after their referral to our program.
We are providing all juvenile detention centers with copies of our physical examination forms that will allow the detention center physician to document the results of the detention center physical examination on our form. This form will accompany the client when he enters our program. The physical examination will be completed prior to the client's entry into the program.
We are working with the Southeast Lancaster Health Clinic to have a physician come to our facility to conduct physical examination on a weekly, or as required basis.
We are attempting to establish an agreement with a local physician's office to perform physical examinations on a cash basis, paid for by the facility. |