INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on August 18, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Bucks County 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff development records, the facility failed to ensure that a sufficient number of staff persons were trained in first aid.Findings:Three of three staff development records reviewed on August 18, 2011 failed to include documentation of first aid training. The project director was interviewed on August 18, 2011 in order to verify first aid training. The project director confirmed that the facility does not have any staff trained in first aid.
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Plan of Correction
One staff member (the one who runs the groups) did have first aid training but the certificate was overlooked. The other two staff members will have first aid training completed by August 31. This wil be monitored by the Project Director. |
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 an interview and a review of administrative procedures, the project failed to document an annual audit of financial activities.Findings:There was no documentation of the annual audit for fiscal year January 1, 2010 through December 31, 2010.The project director was interviewed on August 18, 2010 at approximately 11:00 A.M. The project director confirmed that an annual fiscal audit had not been completed for fiscal year January 1, 2010 through December 31, 2010.
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Plan of Correction
An exception has been applied for and approved by the DOH |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records and confidentiality policy and procedures, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in four of four client records.Findings:Five client records were reviewed on August 18, 2010. Four of the five client records included documentation of communications with third party payers for insurance reimbursement for counseling services. Four client records were required to include documentation of an informed and voluntary consent from the client. The facility failed to obtain an informed an voluntary consent for the disclosure of client identifying information to third party payers in client records # 1, 3, 4 and 5. Client # 1 was admitted on May 5, 2011. Written communications with the clients insurance company in regard to service billing and authorizations was documented in the client record on August 18, 2011, but there was no documentation of an informed and voluntary written consent from the client.Client #3 was admitted on May 26, 2011. Written communications with the clients insurance company in regard to service billing and authorizations was documented in the client record on August 18, 2011, but there was no documentation of an informed and voluntary written consent from the client.Client # 4, admitted February 9, 2011 and discharged May 7, 2011. Written communications with the clients insurance organization in regard to service billing and authorizations was documented in the record on August 18, 2011, but there was no documentation of an informed and voluntary written consent from the client.Client # 5, admitted January 13, 2011 and discharged March 9, 2011. Written communications with the clients insurance organization in regard to service billing and authorizations was documented in the record on August 18, 2011, but there was no documentation of an informed and voluntary written consent from the client.This was reviewed with the facility director on August 18, 2011 and he did not dispute the findings.
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Plan of Correction
All active clients have had signed releases obtained for their files as of 9/12/11. Project Director will train assessor and counselor on requirements as per 255.5, monitor files on a weekly basis, and all future clients with insurance will have releases signed as part of the assessment process. |