INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 3, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, Inc. 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 May 2, 2009.
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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 a review of administrative documentation on April 3, 2009, the facility failed to document an independent annual audit of all financial activities associated with the project ' s drug/alcohol abuse services.
Findings:
The facility documented an annual financial audit for the budget year June 30, 2008 and 2007, but it was not document within six months following the end of the of the projects fiscal year.
The project's fiscal year ended June 30, 2008, but the financial audit was not document until March 30, 2009.
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Plan of Correction
The audited financial statement for fiscal year ending 6/30/08 was completed and documented on 12/01/08.
An Addendum was submitted to DAPL inadvertently.
The CFO will ensure that a copy of the audited financial statement is forwarded to each site and available upon request. The Regional Director will ensure that a copy of the audit is available at the time of inspection. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on an inspection of the facility ' s physical plant, and through an interview with the receptionist, the facility failed to maintain the confidentiality of the client ' s identity.
Findings:
A physical plant inspection was conducted on April 3, 2009 at approximately 12:30 P.M. The client sign-in sheet, in the reception area, was observed to contain the first and last names of clients presently at the facility.
The facility ' s receptionist confirmed the practice of having all client ' s sign the sign-in sheet upon arrival.
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Plan of Correction
The Client Sign-In Sheet has been removed from the front Reception area, effective 4/24/09.
The only point of entry to Holcomb is the waiting room.
The Front Desk Receptionist is provided a Daily Client Roster. As clients enter the waiting room, their names will be checked off and entered as "Present". The Receptionist will then notify the respective clinician of the client's presence.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Base on a review of client records, the facility failed to document a treatment plan update in two of three client records.
Findings:
Three client records were reviewed on April 3, 2009. A treatment plan update was required at lease every sixty days in three client records. The facility did not document a treatment plan update in client records # 2 and 3.
Client record #2 admission date 3/14/08; discharge date 11/3/08; treatment plan documented 3/24/08; treatment plan update not documented during treatment.
Client record #3 admission date 11/6/07; discharge date 9/8/08; last treatment plan update documented 6/23/08.
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Plan of Correction
D&A chart Treatment Plans will be updated every 60 days, effective 4/24/09. Clinical Support Staff will remind respective clinicians of upcoming deadlines by notation on the Service Rendered Sheets at the time of the appointments. This will be an on-going process. The Outpatient Coordinator will review D&A charts and ensure compliance, effective immediately.
The Outpatient Coordinator will review all D&A charts for a three-month period of time and, if they are found to be in compliance, will review charts randomly on a quarterly basis.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultation notes bi-monthly, as stated in their policy and procedures manual, in three of three client records.
Three client records were reviewed on April 3, 2009. Case consultation notes were required in three client records. The facility did not document case consultation notes in client records # 1, 2 and 3.
Client record # 1, admission date 3/12/08, discharge date 7/30/08, case consultation note not documented.
Client record # 2, admission date 3/14/08, discharge date 11/3/08, case consultation note documented on 3/24/08 only.
Client record # 3, admission date 11/6/07, discharge date 9/8/08, case consultation notes documented on 2/4/08 and 4/3/08 only.
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Plan of Correction
The Outpatient Coordinator will supervise clinicians on a bi-monthly basis, review the respective D&A chart information and clinicians' input, write the necessary bi-monthly Consultations, and enter into the respective D&A charts, effective immediately. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of three client records.
Three client records were reviewed on April 3, 2009. Follow-up information was required in three client records. The facility did not document follow-up information within 30 days after discharge, as stated in the project ' s policy and procedures manual, in client records # 1, 2 and 3
Record # 1 was discharged 7/30/08, but follow-up information was not documented at time of inspection.
Record # 2 was discharged 11/3/08, but follow-up information was not documented at time of inspection.
Record # 1 was discharged 9/8/08, but follow-up information was not documented at time of inspection.
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Plan of Correction
The Outpatient Coordinator will supervise clinical staff on a monthly basis on the follow-up procedures when discharging D&A clients. During this supervision, the Outpatient Coordinator will ensure compliance with and knowledge of all policies and procedures.
The Outpatient Coordinator will review D&A charts on a weekly basis, ensuring follow-up compliance within the 30-day discharge period, effective immediately.
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