INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Insights II 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:
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Plan of Correction
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documentation, the facility failed to document an annual financial audit of activities associated with the project's drug/alcohol abuse services.
There was no documentation of an annual financial audit for the years 2019, 2020, and 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 17, 2020 and January 28, 2022, annual licensing inspection.
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Plan of Correction
The President and CEP of New Insights II has entered a contract with a local accounting form and New Insights II is currently undergoing financial audits for the years 2020 and 2021. This audit was started in mid-October and is currently still ongoing. At the conclusion of the current audits being done, the years 2019 and 2022 will be started. We anticipate the audit for the years 2019 and 2022 will be able to begin no later than February 2023. The same firm responsible for completing the current audits will be completing all audits that are due. The President and CEO will oversee the audits and is responsible for working with the accounting firm to answer any questions and keep the auditing process moving smoothly. All four years of financial audits will then be completed by June 2023. |
709.28 (c) 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.
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Observations
Based on two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 1 and # 3.
Client # 1 was admitted on September 30 2022 and was still active at the time of the inspection. A fax to an unknown fax number was sent on November 8, 2022 providing treatment plan and progress notes. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to this number. Also, a fax to an unknown fax number was sent on October 24, 2022 providing the psychosocial and progress notes. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to this number.
Client # 3 was admitted on March 24, 2022 and was still active at the time of the inspection. A fax to a probation officer was sent on July 28, 2022 providing treatment attendance without an informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff are responsible for having their clients sign the proper releases and ensuring that they are in the clinical file. The clinical staff are also responsible for making sure there is a release of information for all parties they are sending treatment information to. In this case, the client was unsure of their referral source's name until they were already engaged in treatment and the clinician sent a treatment update without ensuring the client signed a release when they learned the name of their referral source. As discussed during a staff meeting on Wednesday, December 7, 2022 and led by the Project Director, the Support staff will now also make sure there is a corresponding release for any party they send treatment information to, as well as the clinician double checking that a release is present. This will eliminate any future correspondence from taking place without a release of treatment in place. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative information, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for an annual financial audit of activities associated with the project's drug/alcohol abuse services, were submitted and approved by the Department for the November 17, 2020 and January 28, 2022, annual licensing inspection. The annual financial audit of activities associated with the project ' s drug/alcohol abuse services was again found to be a deficiency in the November 18, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The President and CEO of New Insights II is responsible for ensuring that the financial audits are completed. Due to financial constraints stemming from the COVID 19 pandemic and lost revenue, the audits were unable to be performed. After the January 2022 inspection and subsequent Plan of Corrections were submitted and approved, the President did find a certified public accounting firm to complete the audits needed and signed a contract with them. The audits were scheduled and rescheduled by the auditor numerous times throughout the 2nd quarter and beginning of the third quarter of 2022 before the President signed with another accounting firm to complete the audits, as he was aware they needed completed before our next inspection. The audit for 2020 and 2021 were then started in October of 2022 and are currently still ongoing. Upon completion, the financial audits for 2019 and 2022 will begin. The President will ensure that all Plan of Corrections are followed as approved for future inspections, this was discussed at a board meeting attended by the President on Monday, December 5, 2022. |