INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 7, 2016 by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Impact Counseling Services, 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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705.24 (1) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(1) Provide bathrooms to accommodate staff, clients and other users of the facility.
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Observations
Based on a physical plant inspection conducted on September 7, 2016 at 10:15 am, the facility failed to provide hot water in the restroom next to the rear exit from the facility. Additionally, there were no paper towels available in the restroom.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director will make sure to provide bathrooms to accommodate staff, clients and other users of the facility with adequate supplies of paper towels in the restroom. The project director will also work with the land lord to make sure the water temperature will be adjusted per regulations.
The facility is looking to move into a new facility by the years end. |
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 a review of presubmission materials supplied by the facility and a conversation with the Project Director the facility failed to submit an annual financial audit or request an exception to the regulation requiring an audit.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The project director will work with their independent certified public accountant, Long, Mulhorn, and Criste, for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services. this will be in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The Project Director the facility will submit an annual financial audit or request an exception to the regulation requiring an audit.
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on the review of client records, the facility failed to limit the release of information to an employer to what is permissible according to 4 Pa. Code 255.5 in two client record.
Client record #7 contained a consent to release information to an employer, dated June 15, 2016, that permitted the release of the client's prognosis of the client, nature of the project, a brief description of the progress of the client, a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Client record #10 contained a consent to release information to an employer, dated March 4, 2016, that permitted the release of the client's prognosis of the client, nature of the project, a brief description of the progress of the client, a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
The information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director will train all staff on all information to be released on voluntary consent from the client for the disclosure of information contained in the client record.
With regard to clients employers, staff will be informed that we are only permitted to release the attendance of the client at their therapy sessions.
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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 conducted on September 7, 2016, the facility failed to document an update of the treatment and rehabilitation plan, at least every sixty days, in two of four applicable client records.
Client record #5 contained a treatment and rehabilitation plan update dated 2/10/16. Another review and update of the treatment and rehabilitation plan was due by 4/10/16 however the update was not completed until 4/13/16.
Client record #6 contained a treatment and rehabilitation plan update dated 6/15/16. Another review and update of the treatment and rehabilitation plan was due by 8/15/16 however the update was not documented in the client chart as of the date of the licensing inspection.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director will train staff on treatment plans and regulations surrounding their requirements. Project director will audit charts to ensure all treatment plans are completed every 60 days.
client records #5 will be addressed by training staff to complete the treatment plans 60 days after last one is completed. This is to be done exactly 60 days and not after.
Client record 6 will be addressed by training all staff on completed treatment plans being done 60 days apart from each other and making sure they are kept in the chart. |