INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20, 2008 by staff from the Division of Drug and Alcohol 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 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 training records, a review of the staffing requirements summary report and an interview with the facility director on March 20, 2008, the project failed to train a sufficient number of staff in CPR and First Aid to cover the extended hours of operation. Hours of operation defined on the staffing requirements summary report and posting at the facility revealed the facility is open Monday through Friday from 09:00 to 21:00 with Saturday hours by appointment. Based on the hours of operation three staff need to be trained in CPR and First Aid. A review of the four staff development files on March 20, 2008 revealed one staff person in trained in CPR and no staff are trained in First Aid.
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Plan of Correction
The Site Director of Exton will ensure that two more staff 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 Exton Staff Development manual by the Site Director. |
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 review treatment and rehabilitation plans every sixty days. Five of eight client records reviewed did not document treatment plan reviews every sixty days. Client record #2, 3, 4, 6 and 7 failed to document treatment plan updates every a sixty days. Client record # 7 - Admitted April 3, 2007 with only one treatment plan update for the period of April 3, 2007 through November 30, 2007.Client record #6 - Admitted November 11, 2007 with no treatment plan update. Client record # 4 - Admitted November 11, 2007 with one treatment plan update as of March 20, 2008.Client record # 3 - Admitted November 6, 2006 with no treatment plan update until August 17, 2007. Client record #2 -Admitted October 11, 2007 with one treatment plan update as of March 20, 2008.
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Plan of Correction
The Site Director of Exton will ensure that counselor(s) of records #2, #3, #4, #6, and #7 attend a specialized training on completion of rehabilitation plans in a timely manner. Each staff member will sign off they attended the training & understand documentation needed to comply with state standards. The Site Director will randomly audit charts on a monthly basis until problem is "corrected". |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records the facility failed to document case consultations notes. Three of seven client records reviewed on March 20, 2008 failed to include documentation of case consultation notes. Refer to client records number 3, 6, and 7. Client record # 7 -Admitted April 3, 2007 with one note for the period April 3, 2007 thorough November 15, 2007.Client Record # 6 - Admitted November 13, 2007 with no notes for the period on November 13, 2007 through February 21, 2008.. Client record # 3 - Admitted November 6, 2006 , with one note for the period November 6, 2006 through August 2007.
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Plan of Correction
The Site Director of Exton will ensure that the counselor(s) for client records #3, #6, and #7 attend a specialized training in how to complete/conduct case consults in accordance with state standards. Each staff member will sign off that they comprehend the standard for documentation of case consults. The Site Director will conduct random, monthly chart audits to ensure that the problem has been "corrected". |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records the facility failed to include documentation of follow-up information. Three of four discharged records reviewed on March 20, 2008 did not include documentation of follow-up information within one week of discharge. Organizational treatment management procedures, reviewed on March 20, 2008 require follow-up services occur within one week of discharge. Client records # 5, 6, and 7 were lacking follow-up information. Client record # 7 - Admitted April 3, 2007, discharged November 30, 2007 with no follow -up.Client record # 6 - Admitted November 13, 2007, discharged February 21, 2008 with no follow-up.Client record # 5 - Admitted March 14, 2007, discharged December 5, 2007 with no follow-up.
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Plan of Correction
The Site Director of Exton will ensure that the counselor(s) of client records: #5, #6, and #7 attend a specialized training on follow-up documentation. Each staff member will sign off that they attended the training and understand the intent of this standard. The Site Director of Exton will perform random, monthly chart audits to ensure that this problem has been "corrected". |