INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 3, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Central Outreach Resource and Referral Center 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 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) 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, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of the facility annual report, the governing body failed to make available an annual report to include a statement disclosing the names of officers, directors and principal shareholders for 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Central Outreach Resource and Referral Center has created the following plan of Correction in response to deficiencies 709.22.
The program Director will ensure that the annual Report be listed in the Public source that is local source that displays public information
https://www.publicsource.org/
To ensure that this does not recur, the Program Director and the Board Cheer and one staff member will serve as the annual Reporting Committee that meets two times a year to collect all the organization data and prepare the report.
The report shall include.
The Name of the organization
A list of Broad Numbers
A financial report
The services that we provided
The Data that is collected on a yearly basis.
According to publicsource they update the publicsource on the first of the month.According to Rich Lord Managing Editor. We are putting the information
to gather now and the Publication will be available to the public on the 11/06/2024.the completion date is 11/06/2024
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709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
Based on an administrative review, the facility failed to keep client records readily accessible for a minimum of 4 years following the discharge of a client.
On the date of the inspection, the DDAP representative requested seven discharged client records from the discharged client list provided by the facility; however, only three of the discharged client records were located and provided. The facility representative informed the DDAP representative that four discharged client records could not be located.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Central Outreach Resource and Referral Center has created the following plan of Correction in response to deficiencies 709.29.
Central Outreach Resource and Referral Center has developed a plan of correction
To ensure that this do not recur, the program Director will ensure that the Retention of client records be maintain for the time of 4-7 years. We will develop check and balances of the retention of Record also we have contracted with Armstrong Archives a digital company. That will convert our paper files to digital files for better securities and, accessible digital formats, enhancing both space management of document retrieval with efficiency and accuracy.
The Program Director and and the case manager and the administrative assistant. Will be responsibility of uploading all the paper files, that are maintained in our client program file, and all 3 staff will have a link to login and retrieve and upload clients file at the time they are completed.
Base on Armstrong Archives the process of retrieving and uploading of the files is a 3 month process because of the people uploading the files so base on the the time involved in the process the completion of the retrieving and Retention of client records should be completed on 12/31/2024.
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