INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 13, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, BioCare Recovery Centers 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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709.25(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, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted principles which include reference to the drug and alcohol treatment activities.
The findings include:
The project's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services on July 13, 2015. The facility's fiscal year runs from January 1 through December 31. The facility did not document an independent financial audit for the 2014 fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 709.25 (a), the facility 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
POC: The facility has available our tax return which includes our 2014 Profit and Loss statement. Additionally, we retain a bookkeeper and CPA for financial and tax services. Our gross revenues for drug and alcohol services meets the requirements listed in the Licensing Alert 01-11 with regard to exceptions from 709.25 (a). The Program Director and Executive Director sent a formal request to the DDAP office on July 13, 2015 requesting an exception to 709.25 (a). KARE Services fiscal year is January 1 through December 31, therefore our taxes are completed by April. To prevent this violation is the future, the Program Director and Executive Director will request the exception annually upon completion of our tax return. When we no longer meet the requirements for an exception to Licensing Alert 01-11, we will hire an independent accountant for an annual audit.
Anticipated Completion Date: September 1, 2015 for FY 2014 and for FY 2015 forward by June 1./Program Director and Executive Director will implement.
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709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record which includes case consultation notes in five of ten client records reviewed.
The findings include:
Ten client records requiring a complete client record on an individual were reviewed on July 13, 2015. The facility did not provide a complete client record for client #s 6, 7, 8, 9, and 10.
Client #6 was admitted into treatment on October 13, 2014 and was discharged on June 1, 2015. The facility failed to include documentation of any case consultation notes in the client record as of the date of the inspection.
Client #7 was admitted into treatment on July 24, 2014 and was discharged on January 29, 2015. The facility failed to include documentation of any case consultation notes in the client record as of the date of the inspection.
Client #8 was admitted into treatment on July 23, 2014 and was discharged on January 2, 2015. The facility failed to include documentation of any case consultation notes in the client record as of the date of the inspection.
Client #9 was admitted into treatment on November 19, 2014 and was discharged on June 12, 2015. The facility failed to include documentation of any case consultation notes in the client record as of the date of the inspection.
Client #10 was admitted into treatment on June 6, 2014 and was discharged on December 23, 2014. The facility failed to include documentation of any case consultation notes in the client record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 709.93 (a)(8), 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.
POC: The Clinical Director and Program Director meet weekly to discuss active clients. The Clinical Director, Program Director and Medical Director consult on our active clients as needed but at a minimum monthly. These formal and informal consults are not always captured in the client record and when captured in the EHR, they are not documented as consult notes. The EHR is currently limited in the counseling tab to ?counseling visits? and ?plans? with regard to reason for visit. To prevent this violation is the future, beginning immediately, the Clinical Director or counselor will use the ?ENCOUNTER NOTE? tab to capture case consults and title them as such. For the long term, the Program Director requested a change to the EHR permitting the Clinical Director (or counselor) to title visits, therefore consults and discussions with staff will be documented as Case Consults and include who participated, what was discussed and if the client?s plan requires a change. Clients 6, 7, 8, 9 and 10 are all discharged from the program; therefore those records will continue to not meet the requirements of 709.93(a)(8).
Completion Date: July 14, 2015 / Oversight by Clinical Director and reviewed monthly by Program Director
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