INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Rehab Management, Inc./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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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 7 client records, 6 records had treatment plan updates that were completed after the regulatory timeframe or missing at the time of the inspection.Client #1 was admitted on 1/2/18 and was active at the time of inspection. The comprehensive treatment plan was completed on 1/2/18 and an update was due no later than 3/2/18. However, the update was not completed until 3/9/18. Client #3 was admitted on 1/19/18 and was active at the time of inspection. The comprehensive treatment plan was completed on 1/19/18 and an update was due no later than 3/19/18. However, the update was not completed until 3/27/18. Client #4 was admitted on 12/13/17 and was discharged on 4/3/18. A treatment plan update was completed on 1/22/18 and the next update was due no later than 3/22/18. However, the update was not completed prior to client's discharge.Client #5 was admitted on 12/11/17 and was discharged on 2/28/18. The comprehensive treatment plan was completed on 12/18/18 and an update was due no later than 2/18/18. However, the update was not completed prior to the client's discharge. Client #6 was admitted on 9/5/17 and was discharged on 1/19/18. The comprehensive treatment plan was completed on 9/5/17 and an update was due no later than 11/5/17. However, the update was not completed until 1/17/18. Client #7 was admitted on 9/27/17 and was discharged on 1/19/18. The comprehensive treatment plan was completed on 10/4/17 and an update was due no later than 12/4/17. However, the update was not completed until 1/19/18.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Rehab After Work-Pottstown clinicians will attend a training on May 8, 2018 to review proper treatment plan regulations. This training/review will include treatment plan timelines focusing on the requirement of updates every 60 days, master treatment plan collaboration with the client, and updating treatment plans prior to discharge and when there is a change in level of care.
Clinical supervisor will also review that if a client is still active in treatment, regardless of attendance, a treatment plan update is required every 60 days unless client is discharged prior to timeline.
Bi-weekly Chart Audits, in addition to quarterly audits, will be done throughout the year to ensure treatment plan updates are meeting the timeline regulations of 60 days. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection conducted on 4/16/18 at approximately 2:30 pm, it was observed that the facility's hours of operation were not conspicously displayed to the general public.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The hours of operations for Rehab AFter Work in Pottstown have been placed at the entrance to the facility and can viewed by the general public. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection conducted on 4/16/18 at approximately 2:30 pm, it was observed that the facility failed to display an emergency phone number conspicuously to the general public.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An emergency phone number for Rehab After Work in Pottstown has been placed at the entrance to the facility and can viewed by the general public. |