INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22-23, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Brighter Visions Counseling 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 of activities associated with the project's drug/alcohol abuse services. The annual financial audit for 2018 was requested on January 22, 2020. There was no documentation of a financial audit for 2018 nor an approved exception to the regulation presented. There was no documentation that a financial audit had been completed since the faciltiy was licensed in 2014.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
According to the provisions of Division of Drug and Alcohol Program Licensure Licensing Alert 01-11, February 2011, the Director of Brighter Visions Counseling may submit a request for an exception from the requirements of 28 PA Code § 709.25 (a) governing financial audits. Specific guidelines for exception are detailed in the Alert. A letter requesting exception by those guidelines was submitted to DDAP on January 22, 2020. The facility will follow the direction of the DDAP ruling on that request when received. Other financial records as listed on the Licensing Alert will be available onsite for review as of that ruling. This POC is under the authority and responsibility of the Facility Director. |
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
The facility failed to document a complete client record including medication records, record of service, correspondence and case consultations.Client records were reviewed on January 22 & 23, 2020. Client #1 was admitted on March 20, 2019 and was still active at the time of the inspection. Client record #1 did not include documentation of medication records, correspondence and case consultations.Client #2 was admitted on March 21, 2019 and was still active at the time of the inspection. Client record #2 did not include documentation of record of service and case consultations.Client #3 was admitted on August 7, 2019 and was still active at the time of the inspection. Client record #3 did not include documentation of case consultations.Client #4 was admitted on March 5, 2019 and discharged on August 16, 2019. Client record #4 did not include documentation of case consultations.Client #5 was admitted on June 10, 2019 and discharged on September 25, 2019. Client record #5 did not include documentation of case consultations.Client #6 was admitted on June 4, 2019 and discharged on July 16, 2019. Client record #6 did not include documentation of case consultations.Client #7 was admitted on May 21, 2019 and discharged on August 1, 2019. Client record #7 did not include documentation of case consultations.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client record will include a single listing of all client activity. This record of service will include appointments kept, appointments not kept, dates of any correspondence, medication records, and case closing date. Case consultations will be documented on treatment plans and updates. This plan of correction will be placed into effect with all new charts and all open charts beginning February 6, 2020. This POC is under the authority and responsibility of the Facility Director. |