INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 30, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on June 25, 2007.
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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
A review of four training files documented that the project failed to provide CPR certification and first aid training for a sufficient number of staff to cover all hours of operation.
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Plan of Correction
All 5 staff at Havertown office had current CPR training, but no current documentation of first aid. The site director will ensure/monitor that at least two Havertown staff members enroll in a local first aid training class by 8/30/2007. The staff who attend the training will provide current certification documentation that will be placed in site personel files to ensure compliance with this standard. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The project director failed to establish project goals and objectives with time frames and available resources. A review of governing body information, to include board meeting minutes and quarterly reports, failed to include the necessary documentation.
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Plan of Correction
The president of Rehab After Work stated project goals and included these in the governing body minutes, but without specific goals and time frames included in the report. The President/Project Director with help from the administrative manager, will write down the specific objectives with quarterly time frames reported/included by 6/21/2007. These will be documented & included in the 2007 Governing Body report after approval from the Governing Body by 6/30/2007. |
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
The project failed to document treatment and rehabilitation plan updates with the clients progress in relationship to the stated goals of the comprehensive treatment plan in client record review number 1, 2, 6 and 7.
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Plan of Correction
Four client records did not provide satisfactory treatment plan updates. The site director of Havertown will provide an in-service training for all staff by 7/30/2007. The training will emcompass documentation of progress on treatment plan goals & how to incorporate in the treatment plan updates. All Havertown staff will complete training & sign off that they understand this standard. The site director will perform follow-up random chart audits on a monthly basis until the standard is in full compliance. |
709.93(a)(2) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(2) Medication records.
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Observations
The project failed to document a complete client record in three of eight files reviewed. Medication dose and dose frequency was not documented in record number 3. Medication dose was not documented in record numbers 2 and 8.
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Plan of Correction
Three client files did not show completed medication information during survey date. The site director of the Havertown office will conduct and in-srevice training for all Havertown staff by 7/30/2007. The in-service will encompass medication reporting, including dose & dose frequency. It will also encompass training on where accurate medication information is documented on the client record. All staff will sign off that they understand thhis standard. The site director will perform monthly, random chart audits until standard is in full compliance. |