INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 20-22, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SOAR Corp. 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:
|
Plan of Correction
|
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
|
Observations
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant to complete an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of the facility 's fiscal year.The findings include:The facility's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services on November 22, 2013. The last fiscal audit documentation was dated February 28, 2012 for fiscal years ending September 30, 2011 and September 30, 2010. There was a review completed by an audit company June 17, 2013, but they stated in the review that they did not audit the financial books and therefore were not rendering an opinion. The project/facility director reported that the project is now on a calendar year rather then a fiscal year for reporting.
|
Plan of Correction
Project Director has already informed the SOAR Corp Board who have hired an independent audit/accounting firm to to an official audit for 1/1/2013 to 12/31/2013. The Board will also look into doing an audit for 1/1/2012 to 12/31/2012 at the same time so that SOAR will be in compliance with 2012 and 2013. These audits will be official ones and not simpliy a listing of assets and liabilities. Project Manager will follow-up to make sure that this is completed in a timely manner. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records, the facility failed to include the reason for termination in one of one client records reviewed. The findings include:Twelve client records were reviewed November 20-22, 2013. One client record was reviewed for documentation of intent to involuntarily terminate the client. Client # 1 was admitted June 10, 2009 and discharged July 15, 2013. The client was presented with a notice of intent to involuntarily terminate dated July 15, 2013. However, the facility uses a generic form that lists categories to be checked. Noncompliance with facility rules was checked, but did not inform the client of the specific form of noncompliance. The form does not allow for the facility to include the actual reason for the termination.
|
Plan of Correction
Executive Director of Chester MAT program has alreasdy replaced the old form with a new one that is much clearer for when the counselor goes to fill one out. Form specifically requests that information be added on a seperate line and allows the counselor to add detailed information. Memo and short in-service will be done so that all clinical staff is aware of changes in this form. Clinical Supervisors will monitor for compliance. |
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
Based on the review of client records, the facility failed to document complete discharge summaries in seven of seven client records reviewed. The findings include:Twelve client records were reviewed November 20-22, 2013. Discharge summaries were required in seven client records. Client #1 was discharged July 15, 2013. There was no reason for entering treatment nor services offered as a part of the discharge summary. It also failed to include the status of the client upon discharge. Client #2 was discharged August 27, 2013. There was no reason for entering treatment nor services offered as a part of the discharge summary. It also failed to include the status of the client upon discharge. Client #3 was discharged September 19, 2013. There was no reason for entering treatment nor services offered as a part of the discharge summary. Client #4 was discharged September 15, 2013. There was no reason for entering treatment nor services offered as a part of the discharge summary. Client #5 was discharged October 23, 2013. There was no reason for entering treatment nor services offered as a part of the discharge summary. Client #6 was discharged November 2, 2013. There was no reason for entering treatment nor services offered as a part of the discharge summary. It also failed to include the status of the client upon discharge. Client #10 was discharged October 21, 2013. There was no reason for entering treatment nor services offered as a part of the discharge summary.
|
Plan of Correction
New forms will be developed by Executive Director of Chester that will add prompts for the issues in question. New forms will be given out to all clinical staff along with a memo explaining how to do one correctly. If still problematic an in-service will be held for all clinical staff of both facilities reviewing the right way to do a discharge summary. |