INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Child Guidance Resource Centers 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(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.
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Observations
Based on a review of administrative documentation, the project failed 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 February 9, 2016. The facility's fiscal year being reviewed was from July 1, 2014 through June 30, 2015. The facility provided documentation that the annual audit was completed; however, said documentation was only a draft version of the audit and did not have a signature or date from the independent public accountant at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) A finalized signed financial audit will be published by 2/26/16.
2) Going forward, a final signed annual audit will be completed by 12/31 each year. CGRC's finance department will maintain communication with auditing firm and all involved entities to insure this process is completed in a timely manner.
3) Facility Director and Quality Improvement Director will work together to monitor progress towards completion annually.
4) Corrective action completed 2/26/16.
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709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes follow-up information and case consultation notes, in three of three client records reviewed.
The findings include:
Three client records requiring a complete client record on an individual were reviewed on February 9, 2016. Specifically, the facility did not provide case consultation notes in client record #1 and did not provide follow-up information in client record #'s 1, 2, and 3.
Client #1 was admitted into treatment on June 29, 2015 and was discharged on October 28, 2015. The facility failed to include documentation of any case consultation notes in the client record. Additionally, the facility failed to include documentation of any follow-up information as of the date of the inspection.
Client #2 was admitted into treatment on June 30, 2015 and was discharged on August 12, 2015. The facility failed to include documentation of any follow-up information as of the date of the inspection.
Client #3 was admitted into treatment on August 5, 2015 and was discharged on October 4, 2015. The facility failed to include documentation of any follow-up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) Unable to correct missing consultation form because client has been discharged. Clinician made follow up calls to discharged clients on 2/26/16.
2)Project Director retrained Facility Director on procedure for conducting case consultations on 2/17/16 and Facility Director retrained clinician on 2/18/16. Going forward, case consults will be completed as necessary and documented accordingly. The next two case consultations due will be completed and then reviewed by Director of Quality Improvement.
The process for follow up post discharge has been changed from sending a letter to making a phone call after 7 days post-discharge. This phone call will be documented in an informational progress note. This new process was reviewed with the clinician on 2/18/16 and will be followed going forward. The next 2 clients requiring post-discharge follow up will be reviewed by the Director of Quality Improvement for compliance with this process.
3)Facility Director and Quality Improvement Director will monitor implementation of this plan as described above.
4)All corrective actions were completed as of 2/26/16. |