INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 16, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab After Work 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 April 10, 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 administrative documentation, the facility failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility ' s administrative documentation was reviewed and an interview with the project director was conducted on March 2, 2010. The facility was required to document an annual audit of financial activities. The facility did not document a financial audit for the 2008-2009 fiscal year.
The project director confirmed that a financial audit had not been completed.
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Plan of Correction
The executive director shall submit a written request within 90 days for a waiver of this regulation. If the waiver is not granted, then the executive director of Rehab After Work will begin the process of arranging for an independent, external audit with approval from the governing body president. The executive director will monitor progress in the area on a monthly basis and note progress in the gorverning body minutes (manual). |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a tour of the facility ' s physical plant and an interview with the facility director, the facility failed to secure all client records within locked storage containers.
The findings include:
A tour of the facility ' s physical plant was conducted on March 16, 2010 at approximately 2:00 PM. The facility was required to secure all client records within locked storage containers. The facility did not secure client records within a locked storage container.
Drug and alcohol client records were stored in an unlocked file cabinet in the same storage room used to store mental health client records and also other non-record related items. Base on an interview with the facility director, it was determined that non-drug and alcohol employees had free access to this storage room.
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Plan of Correction
By 4/3/10, The site director of Jenkintown will ensure that the unlocked file cabinet which stores client records will be fixed & a new lock installed on the files. The storage area will be locked as usual protocol. Effective immediately, the Mental health files will be stored in a seperate area, until the locksmith repairs the file cabinet. The site director of Jenkintown will distribute new keys to all Rehab after Work counselors at the Jenkintown site. |
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 the review of client records, the facility failed to document informed and voluntary consent from the client for the disclosure of information contained in two of six client records.
The findings include:
Six client records were reviewed on March 16, 2010. All six records required documentation of informed and voluntary consent. The facility did not document informed and voluntary consent from the client for the release of information in client records # 2 and 4.
Client records # 2 and 4 contained correspondence with an insurance company, but the facility did not document a signed consent from the client to release the client ' s information.
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Plan of Correction
The site director of Jenkintown will ensure that training begins immediately and is ongoing. The site director of jenkintown will meet with the counselor of client records #2 & #4 on 3/24/2010 and review the state regulations and company guidelines for informed and voluntary consent - most noteably regarding correspondence with insurance companies. The counselor of record will sign off that they understand informed and voluntary consent and that proper releases be obtained. The site director of jenkintown will conduct random, monthly chart audits to ensure that the counselor of record is in full compliance with the standard. |