INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 4, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Little Creek Outpatient 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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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 provide documentation of an annual financial audit of the activities associated with the project's drug and alcohol abuse services for the project's prior fiscal year.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility Owners contacted 5 Certified Public Accountants between 10/3/18 and 10/4/18, in order to have the Audit for FY 2017 completed properly. This audit will be completed by 12/31/18 and an audit for FY 2018 will be scheduled with said CPA will occur no later than 7/1/19. Both audits will remain on file. The Project Director will assure the hired CPA includes a letter indicating an audit was performed using generally accepted accounting principles, and contains an opinion on the results found. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
The facility failed to provide documentation that clients were oriented to the project during the intake/admission period in eight of eight client records reviewed.
Client #1 was admitted on August 10, 2018 and was active at the time of inspection.
Client #2 was admitted on March 10, 2018 and was active at the time of the inspection.
Client #3 was admitted on June 28, 2018 and was active at the time of the inspection.
Client #4 was admitted on September 6, 2018 and was active at the time of the inspection.
Client #5 was admitted on March 6, 2018 and was discharged on September 1, 2018.
Client #6 was admitted on November 11, 2017 and was discharged on March 7, 2018.
Client #7 was admitted on May 9, 2018 and was discharged on August 15, 2018.
Client #8 was admitted on February 1, 2018 and was discharged on May 23, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Client Handbook was created by the Lead Counselor for all clients receiving services at Little Creek Outpatient Services. The purpose of the Handbook is to inform clients of the Project's schedule, program structure, rules and guidelines, hours of operation, cancellation policy, and Client and Employee rights and responsibilities. The Handbook was completed by 10/15/18 and reviewed by the Clinical Director on the same date.
This Handbook will be given to all admissions and reviewed in the first session with their clinician. Clients will sign off on an Orientation Questionnaire Form no later than their 3rd treatment experience, verifying they have received and reviewed the Handbook and have been thoroughly oriented to the Program. The Clinical Director will assure Handbooks are given to each Admission and will review charts to assure verification of their orientation to the program was done. |