INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 28, 2023 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) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the March 2022 through January 2023 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts during every fire drill reviewed.
The facility's hours of operation are Monday through Friday 9:00AM - 9:00PM. All fire drills conducted, during the reviewed period, were completed on Thursdays from the hours of 1:00PM through 2:30PM. None of the fire drills were conducted on different days of the week or during the facility's morning and evening hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to abide by DDAP regulation, safety officers and clinical supervisors with the support of clinical director, quality manager, and director of compliance will conduct fire drills at different times of the day, different days of the week, and during different staffing shifts during facility hours of operation. Identified staff listed will re-train on -site staff within 30 days with full compliance expectation as of 5/28/2023. Quarterly audits will occur by quality manager and clinical director in order to ensure consistency in accordance with the regulation. |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in one of seven client records reviewed.
Client # 4 was admitted on November 16, 2022 and was discharged on December 27, 2022. The release of information form to a primary care physician was signed and dated by a witness on November 16, 2022, but the form did not include the dated signature of the client.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The supervisor will conduct random chart audits of each clinician at a rate of two charts per clinician monthly to randomly inspect that proper consent is obtained that includes client signature. An onsite group supervision will be conducted with all staff to reinforce the consent requirements. |
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 document an individual treatment and rehabilitation plan within the timeframe documented in the facility policy in two of five applicable client records reviewed.
The facility policy and procedure manual states that the individual treatment and rehabilitation plan is to be completed within the first four sessions or thirty days of the level of care assessment, whichever occurs first.
Client # 2 was admitted on December 30, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than January 4, 2023; however, the individual treatment and rehabilitation plan was not completed until February 9, 2023.
Client # 3 was admitted on January 14, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than January 19, 2023; however, the individual treatment and rehabilitation plan was not completed until February 27, 2023.
These findings were 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 plans are being completed within policy timeframes. Re-training will occur during group supervision within 30 days, with expectation of full compliance by 5/28/23. |