INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19, 2008 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 18, 2008.
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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
Based on a review of three staff development files, hours of operation, staffing requirements summary report and an interview with the facility director on March 19, 2008 the facility does not have sufficient staff trained in CPR and first aid to cover the hours of operation. The hours of operation are defined as Monday through Friday, 09:00 to 21:00. Two individuals are CPR certified and no staff have been trained in First Aid.
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Plan of Correction
The Site Director of Northeast will ensure that two more NE staff will attend the 3/28/2008 CPR/First Aid training held by Cardiac Care Associates at Center City Rehab After Work location. Proof of the training & proof of staff attendance will be placed in the Northeast Staff Development manual by the Site Director. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
The facility director failed to inform the Department of a change in authorized maximum capacity. Based on a review of the organizations census reports, the facility summary report, clients records and an interview with the facility director on March 19, 2008 it was revealed the facility census was 77 on March 19, 2008 while the authorized maximum capacity on March 19, 2008 was 60.
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Plan of Correction
The Site Director of the Northeast will send a letter to the Division of Drug and Alcohol Program Licensure requesting an increased capacity of 120 for the Northeast office census. The letter will include staffing patterns of the Northeast office & will avoid, if approved, further problems in this area. The Site Director will monitor progress/response status regarding capacity increase request. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
The project failed to obtain informed and voluntary consent to disclose client information contained in the client record. Three of eleven client records reviewed on March 19, 2008 documented incomplete authorizations to release information with client signatures. Client record # 2 - The section on specific information to be disclosed was not completed, but the client had signed the form. Client record #8 - The section on specific information disclosed was not completed, but the client had signed the form. Client record # 10 - The section on specific information disclosed was not completed, but the client had signed the form.
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Plan of Correction
The Site Director of Northeast will ensure that the counselor(s) of client records #2, #8, and #10 attend a specialized, on-site training regarding informed & voluntary consent and release of information. Counselor(s) will be required to sign off that they attended the training & understand state standards regarding this area. The Site Director will conduct random, monthly chart audits until problem has been corrected. |
709.92(a) 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:
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Observations
Based on a review of client records the facility failed to develop treatment and rehabilitation plans within fourteen days of admission as required in the organization treatment management procedures. Three of eleven client records reviewed on March 19, 2008 did not document treatment plans within fourteen days of admission as required in the treatment management procedures manual. Client record # 4 - The client was admitted on September 28, 2007, with a treatment plan established on November 20, 2007. Client record #6 - The client was admitted on February 20, 2008, with a treatment plan established on March 13, 2008. Client record # 11 - The client was admitted on January 30, 2008, with a treatment plan established on March 13, 2008.
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Plan of Correction
The Site Director of Northeast will endure that the counselor(s) of records #4, #6, & #11 attend a specialized training on completion of rehabilitation plans in a timely manner. Each staff member in attendance will sign off with respect to training attendance & understanding of documentation needed to comply with state standards. The Site Director will randomly audit charts on a monthly basis until problem is "corrected". |