INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11 -12, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Services of Warren County, 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 July 9, 2008.
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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 conversation with the director on 6-11-08, the facility failed to complete an annual audit for the 2007 fiscal year.
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Plan of Correction
Executive Director wrote and sent a letter to Cheryl Williams, Director, Division of Drug and Alcohol Program Licensure requesting an exemption to the policy for an annual audit to an audit every other year and reviews during subsequent years. The agency has received confirmation of the request for the exemption by the Division of Drug and Alcohol Program Licensure and would receive a decision by the middle of July 2008. Currently the agency is awaiting approval for the exemption. The executive Director will be responsible for complying with the regulation. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of four client records on 6-12-08, the facility released information to a Single County Authority funding entity that exceeded the limitations imposed at 4 Pa. Code subsection 255.5 in one of those four records, specifically client record #4.
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Plan of Correction
The Supervisor of the Substance Abuse Services Program has changed the signed releases of information at Intake for the Single County Authority (SCA) into two separate releases of consent from the one previously. One is now signed for billing complying with confidentiality under PA-255.5 and the other release is signed for coordinating care of treatment under Federal Law -42CFR, Part 2. Currently in compliance with the regulation as of June 12, 2008.
Supervisor of the Substance Abuse Services Program and Substance Abuse Therapists will be responsible for attaining the appropriate releases and maintaining compliance
Supervisor of the Substance Abuse Services Program did a review of confidentiality under PA-255.5 and 42CFR, Part 2 to ensure compliance with confidentiality with the Substance Abuse Therapists on June 18, 2008. Supervisor of the Substance Abuse Services Program will continue to conduct Confidentiality training at Orientation with new therapists now and in the future to ensure compliance with confidentiality. In addition, Supervisor of the Substance Abuse Services Program will review at least five clientâ??s files from each therapist each month to ensure compliance with licensing standards and regulations.
New SCA releases of confidentiality will be signed by all current active SCA clients including client #4 to meet the licensing regulation by July 15, 2008 that reflect one for billing under PA-255.5 and the other for coordinating care under 42CFR, Part 2.
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709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the policy and procedures manual on 6-11-08 and conversations with the director on 6-11-08 and 6-12-08, the facility failed to provide a follow-up policy that includes non-successful discharges.
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Plan of Correction
Supervisor of the Substance Abuse Services Program added a policy to address the follow up of discharged clients as not completing treatment. The policy reads: Substance Abuse Therapists will follow up with clients discharged as not completing treatment thirty days after discharge by a phone call to inquire if the client would like to return to treatment or has followed through with another Drug and Alcohol Treatment Facility. The Substance Abuse Therapists will document the phone call on the Referral/Follow-Up Form in the clientâ??s file. Supervisor of the Substance Abuse Services Program and Substance Abuse Therapists are responsible for maintaining compliance with the licensing regulation.
Supervisor of the Substance Abuse Services Program has informed Substance Abuse Therapists of the new policy and Supervisor of the Substance Abuse Services Program will address the policy at Orientation of new therapists.
Furthermore, the Supervisor of the Substance Abuse Services Program one time of month will remind Substance Abuse Therapists via email and/or at supervision times to follow up with discharge clients not completing treatment after thirty days and to document in their file in the referral/follow up form according to the Substance Abuse Services Program Policy to ensure compliance with the licensing regulation.
The Substance Abuse Services Program is currently in compliance with the licensing regulation as of June 25, 2008.
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