INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 11, 2008 through March 13, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab. Management, Inc. 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 11, 2008.
|
Plan of Correction
|
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.
|
Observations
Based on a review of staff development records, personal records, the staffing requirements facility summary report, and a interview with the facility director on March 13, 2008, the facility failed to train a sufficient number of staff in CPR and first aid to cover all facility hours of operation. A sufficient number of staff are not trained to cover evening hours, and scheduled and unscheduled leave time.
|
Plan of Correction
The Site Director of Paoli will ensure that the three Paoli staff members attend the 3/28/2008 CPR/First Aid training being held by Cardiac Care Associates at the Center City Rehab After Work location. This will ensure that a sufficient number of Paoli staff are trained to cover evening hours and scheduled/unschedule leave time. |
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.
|
Observations
Based on a review of client records the facility failed to update treatment and rehabilitation plans every sixty days. Two of four active client records reviewed on March 13, 2008 failed to include documentation of treatment and rehabilitation plan updates every sixty days.
Client Record # 2, Admitted October 31, 2007 - No treatment plan update documentation for February 13, 2008. Client record # 3, Admitted December 14, 2007 - No treatment plan update documentation for February 14, 2008.
|
Plan of Correction
The Site Director of Paoli will ensure that the therapist's of record on Record #2 & Record #3 will attend a specialized training on rehabilitation plan updates and documentation standards on timeliness of plan updates. All applicable staff will sign off on attending & understanding the state requirements. The Site Director will randomly audit charts on a monthly basis until problem is "corrected". |