INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the December 21, 2009 through December 23, 2009 licensure renewal inspection. The follow-up inspection was conducted on June 2, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Discovery House Ha 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 June 26, 2010.
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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 the review of facility financial documents during the onsite licensing inspection of 12/23/2009, the facility failed to document an audit for the year ended 12/31/2008.
The findings included:
Division staff reviewed the documentation presented when the annual audit was requested. The documentation presented by the facility director consisted of a financial statement for the year ended 12/31/08. The letter from the accountant stated"...we have not audited or reviewed the accompanying financial statements and do not express an opinion or any other form of assurance on them." There is a statement of income and expenses and balances. The documentation presented failed to meet the requirement for the annual financial audit. Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction.
The facility still has not corrected this item.
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Plan of Correction
Discovery House will conduct an audit for FY 2010. We will submit a 2009 compellation review and an engagement letter for 2010. Program Director will be responsible. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on the review of client records on June 2, 2010, the facility failed to document discharge summaries which included the reasons the client came into treatment and the services offered to each client in nine of ten client records.
The findings include:
Twenty-four client records were reviewed on June 2, 2010. Ten of those client records were closed client records and were required to document a discharge summary which included the reasons the client came into the facility for this treatment episode and the specific services provided to the client during the treatment episode.
The discharge summary did not include the reasons the client came into the facility for this treatment episode and did not include that the client received individual and group treatment services in nine of ten client records reviewed, #15, 16, 17, 19, 20, 21, 22, 23 and 24.
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Plan of Correction
Clinical Supervisor and lead counselor have provided a training to clinical staff on writing discharge summaries. This training focused on documentation of reasons clients entered treatment and services offered while the client was in treatment. This training took place on 6/03/10. Clinical Supervisor will monitor for compliance by approving and signing off on all discharge summaries to ensure compliance. Program Director will randomly review discharge summaries to also ensure compliance. Both Clinical Supervisor and Program Director will be responsible and this process has started as of 6/7/10. |