INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation, 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.
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Plan of Correction
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the 2012 annual report, the governing body failed to make available to the public an annual report which included a statement disclosing the names of officers, directors and principal shareholders.The findings include:The 2012 annual report was reviewed on December 2, 2013. The facility made the 2012 annual report available to the public; however, the 2012 annual report did not include a statement disclosing the names of officers, directors and principal shareholders. The Clinical Supervisor did not dispute the findings.
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Plan of Correction
The Project Director will make certain that the Annual Report will include a statement disclosing the names of officers and directors (there are no principle share holders). This will replace the Annual Report and will be completed by 1/15/14. The Project Director will review the Annual Report 3 months before it is available to the public to guarantee that the names of officers and directors are included, while reviewing the report the Project Director will ensure all of the components are included to be sure this deficiency does not recur. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records, the facility failed to demonstrate its efforts toward informing clients of all their rights in five of five client records.The findings include:Five client records were reviewed on December 4, 2013 for documentation that clients had been informed of all their rights. The facility failed to demonstrate that clients # 1, 2, 3, 4 and 5 were informed of the following client rights: (3) A client has the right to inspect their own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file. (4) The client has the right to appeal a decision limiting access to his records to the project director. (5) The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records. (6) The client has the right to submit rebuttal data or memoranda to his own records. The Clinical Supervisor confirmed the findings.
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Plan of Correction
The project director will ensure that the client rights form is changed to include the clients right to review their record as stated in regulation 709.30 #3-#6. At the time of the inspection clients were not being properly informed of their rights as stated in the aforementioned regulation. The clinical supervisors will supervise the counselors to implement this change starting on 2/6/14. Both the clinical supervisors and project director will monitor implementation and compliance to ensure this deficiency does not recur. Monitoring will occur with a monthly review of all charts during monthly supervisions. |