INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 17 -18, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Familylinks, 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 and a plan of correction is due on July 17, 2009. .
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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 the audit for July 1, 2007 through June 30, 2008, the project failed to complete the audit following the end of the project's fiscal year.
The findings include:
A review of the annual audit was conducted on June 15, 2009. The project's audit for July 1, 2007 through June 30, 2008 was due to be completed no later than December 30, 2008. The project's audit was not completed until March 26, 2009.
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Plan of Correction
709.25 (a) Fiscal Management.
Sr. Program Manager will coordinate with Finance Director to insure that an annual audit is completed yearly by an independent public accountant. The documentation of the annual audit will presented to licensing representative at the next visit.
Completion Date: September 30, 2009
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan review and updates within sixty days, in two of three client records.
The findings include:
Eleven client records were reviewed on June 17 - June 18, 2009. Six client records reviewed were from the outpatient program. Three client records required treatment plan review and updates. Per the facility policy, treatment plan review and updates are required to be completed every sixty days. The facility failed to document treatment plan review and updates within sixty days, in client records # 5 and 6.
In client record # 5, the client was admitted on November 3, 2008. The comprehensive treatment plan was completed on January 2, 2009. The first treatment plan update was due by March 2, 2009 and was completed March 5, 2009. The second treatment plan update was due by May 5, 2009 and was not completed until May 21, 2009.
In client record # 6, the client was admitted on October 8, 2008. The comprehensive treatment plan was completed on October 27, 2008. The first treatment plan update was due by December 27, 2008 and completed within sixty days on December 15, 2008. The second treatment plan update was due by February 15, 2009 and was not completed until February 26, 2009. The third treatment plan update was due by April 26, 2009 and was not completed until May 4, 2009.
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Plan of Correction
Sr. Program Manager and Clinical Supervisor will perform quality assurance reviews on active charts monthly to ensure that all treatment plan updates includes client's progress and that all updates are completed every sixty days. Clinical Supervisor will review with therapist in clinic meetings monthly that all treatment plan updates are due every sixty days.
Completion Date: September 30, 2009 |