INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 5, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lehigh Valley Drug and Alcohol Intake Unit, 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 an administrative review, the project failed to 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 that included reference to the drug and alcohol treatment activities for the facility's 2021-2022 fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Executive Officer (CEO) reached out to current independent certified public accountant for issues raised during DDAP audit on 4/5/23. They have agreed to finalize financial audit for Fiscal Year 2022 by 5/31/23. They will be completing future audits by deadline of December the latest as indicated by DDAP guidelines. |
709.44(b)(4) LICENSURE Follow-up Information
709.44. Client records.
(b) If applicable, the project shall also include the following items in the client record:
(4) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in three of six applicable client records reviewed.
Client #1 was admitted on July 1, 2022 and was discharged on July 1, 2022. There was no follow-up information documented in the record at the time of the inspection.
Client #2 was admitted on August 3, 2022 and was discharged on August 3, 2022. There was no follow-up information documented in the record at the time of the inspection.
Client #8 was admitted on February 20, 2023 and was discharged on February 20, 2023. There was no follow-up information documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Designated staff will be conduct follow ups on weekly basis as needed and document that the client followed recommendations made during assessment process. Record of weekly follow ups will be kept and reviewed monthly by supervising staff effective 5/1/23. |