INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Guidance Center 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 materials, the facility failed to document a financial audit for the July 1, 2019 - June 30, 2020 fiscal year.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. As of 6/10/21, The Guidance Center ("TGC") Finance Department, Senior Director of Operations, had already identified the 2019-2020 fiscal year audit as not being completed. The reason(s) for this delay are not known, as the employees responsible for the completion of the annual external audit are not currently employed by TGC. Current Finance Department Senior Director of Operations, recently (in April 2021) coordinated the completion of the 2018-2019 external audit by an independent certified public accountant; due to this lag, the 2019-2020 audit could not be started until the previous year's audit was complete. Management subsequently went out to bid for the 2019-2020 fiscal year audit and the selection of a new independent certified public accountant was made in early June 2021.
2. As of June 10, 2021, the Finance Department, Senior Director of Operations, has already initiated the 2019-2020 audit with the new accounting firm and are in the documentation gathering and informational sharing phase of the audit. We anticipate completion within 60-90 days of the above date. This independent certified public accounting firm has also been engaged for the 2020-2021 and 2021-2022 audits.
3. Quality and compliance will add the financial audit as a key indicator for the fiscal audit within the agency within the next 2 audit cycles. |
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 a review of client records, the facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in five of eight records reviewed on June 10, 2021.The facility obtained authorization for drug and alcohol services without written consent of the client in the following records.Client # 2 was admitted April 13, 2020 and discharged February 3, 2021. Authorization was obtained January 1, 2021.Client # 3 was admitted June 11, 2019. Authorization was obtained January 1, 2021.Client # 4 was admitted February 1, 2021. Authorization was obtained February 1, 2021.Client # 7 was admitted March 15, 2021. Authorization was obtained March 15, 2021.Client # 8 was admitted January 11, 2021 and discharged March 24, 2021. Authorization was obtained January 11, 2021.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the June 12 - 13, 2018, April 24 - 25, 2019 and November 17, 2020 licensing inspections.
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Plan of Correction
1. Drug and Alcohol treatment team staff were provided with an overview of the on-site inspection findings on 6/24/21.
2. Drug and Alcohol treatment staff were provided with an overview on correct completion of consents in accordance with regulation 709.28. This review occurred on 6/29/21.
3. Drug and Alcohol Project Director and Clinical Supervisor met with Executive Director on 6/22/21. The need for increased communication between the fiscal department and treatment staff regarding insurance changes was reviewed and emphasized.
4. Quality and Compliance will add a review of consents to their indicator on the internal quality reviews. This indicator will be applied to the next scheduled quarterly audit.
5. Beginning 7/1/21, the clinical supervisor will complete monthly client chart audits to ensure that consents are being captured appropriately and accurately. The charts that will be reviewed will be the previous month's admissions.
6. All current and future clients will have consents for insurance successfully completed before information is release to their insurance company. |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that included the dated signature of the client in four of eight client records reviewed on June 10, 2021.Consents were documented during the intake process in the following client records.Client # 1 was admitted December 4, 2020. A consent for a pharmacy did not include the dated signature of the client. Client # 4 was admitted February 1, 2021. Consents for probation and a social service agency did not include the dated signature of the client. Client # 7 was admitted March 15, 2021. Consents for an emergency contact, insurance and a social service agency did not include the dated signature of the client. Client # 8 was admitted January 11, 2021 and discharged March 24, 2021. Consents for an emergency contact, insurance, friend and a social service agency did not include the dated signature of the client. The findings were reviewed with staff during the licensing process.
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Plan of Correction
1. Drug and Alcohol treatment staff were provided with an overview of the on-site inspection findings on 6/24/21.
2. Drug and Alcohol treatment staff were provided with an overview on correct completion of consents in accordance with regulation 709.28. This review occurred on 6/29/21.
3. Quality and Compliance will add a review of consents to their indicator on the internal quality reviews. This indicator will be applied to the quarterly audit that will take place in August of 2021.
4. Beginning 7/1/2021, the clinical supervisor will complete monthly client chart audits to ensure that consents are being captured appropriately and accurately. The charts that will be reviewed will be the previous month's admissions.
5. All current and future clients will have complete consents filled out with signature and date. |
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 quarterly case consultation notes, as per facility policy, in two of five client records reviewed on June 10, 2021.No case consultation notes were documented in the following client records.Client # 5 was admitted April 9, 2020 and discharged February 18, 2021.Client # 6 was admitted November 11, 2019 and discharged February 10, 2021.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Drug and Alcohol treatment team staff were provided with an overview of the on-site inspection findings on 6/24/21.
2. Project Director completed review of all D&A clients and projected out quarterly reviews for the remainder of the calendar year on a spreadsheet that is accessible by all treatment staff. This process and spreadsheet was reviewed with treatment staff on 6/22/21 and 6/24/21.
3. Project Director set a schedule for quarterly reviews to occur the first Tuesday of each month to capture all clients in a timely and effective manner.
4. Clinical Supervisor is tasked with ensuring that quarterly reviews are occurring as scheduled and documentation maintained in the electronic health record beginning 6/22/2021.
5. Quality and compliance will add quarterly reviews to their key indicators beginning August 2021. |