INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 18, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Rehab After Work 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:
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Plan of Correction
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705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the March 2023 through December 2023 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions. The fire drill log for May 1, 2023 documented that the fire drill was conducted at 7:30AMl which is outside of the facility's hours of operation. The facility's posted hours of operation are Monday through Thursday from 8:00AM to 8:00PM and Friday from 8:00AM to 4:00PM. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward to abide by this DDAP regulation, the office managers with the support of the clinical supervisors will complete a fire drill on different business days of the week (Monday-Friday), at different times of the day including morning, afternoon, and evening hours within the scope of posted facility hours. This will commence immediately and have full compliance by correction action date. Clinical supervisor will review monthly fire drills to ensure full compliance. |
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 a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in one of two applicable client records reviewed.Client #4 was admitted on September 26, 2023 and was discharged on December 18, 2023. The comprehensive treatment and rehabilitation plan was completed on September 30, 2023 and the first update was due no later than November 30, 2023; however, the update was not completed prior to discharge. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and executive director with the support of clinical director and quality manager will complete monthly chart audits to ensure treatment plan updates are being completed within policy timeframes. Re-training will occur during group supervision within 30 days, with expectation of full compliance by 3/12/24. |