INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on July 14, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Clear Choices LLC 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
The facility failed to document an annual financial audit for the fiscal years ending December 31, 2017 and December 31, 2018.
This is a repeat citation from the September 11 - 12, 2018, February 7, 2019 and August 1 - 2, 2019 inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director has applied for an exception from DDAP regarding financial audits. If the exception is not granted, Facility Director will have the 2017 and 2018 Financial Audits completed no later than 12/31/2020. Facility Director will ensure that without exception, annual financial audits will be completed annually and will maintain documentation on site for future inspections. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
The facility failed to comply with plans of correction approved by the Department.
On July 14, 2020, an off-site inspection was conducted, which included a review of the 2017 and 2018 annual financial audit deficiencies from inspections completed on September 11 - 12, 2018, February 7, 2019 and August 1 - 2, 2019.
As a result of the September 11 - 12, 2018 inspection, the facility submitted a plan of correction stating the financial audit for 2017 would be completed by December 31, 2018. This plan of correction was approved by the Department on October 22, 2018. The facility did not complete the audit by December 31, 2018.
As a result of the February 7, 2019 inspection, the facility submitted a plan of correction stating the financial audit for 2017 would be completed by June 30, 2019. This plan of correction was approved by the Department on April 4, 2019. The facility did not complete the audit by June 30, 2019.
As a result of the August 1 - 2, 2019 inspection, the facility submitted a plan of correction stating the financial audit for 2018 would be completed by October 31, 2019. This plan of correction was approved by the Department on September 3, 2019. The facility did not complete the audit by October 31, 2019.
As of July 14, 2020, the facility had not completed the 2017 and 2018 financial audits and failed to comply with the Department-approved plans of correction.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director has applied for an exception from DDAP regarding financial audits. If the exception is not granted, Facility Director will have the 2017 and 2018 Financial Audits completed no later than 12/31/2020. Facility Director will ensure that without exception, annual financial audits will be completed annually and will maintain documentation on site for future inspections. Facility director will ensure that all Plans of Correction that arise from Inspections will be completed timely in the future and will maintain accurate documentation on site regarding the corrections. |