INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 5, 2008 and August 6, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Spring-Ford Counseling Services, 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 September 5, 2008.
|
Plan of Correction
|
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:
|
Observations
Based on a review of administrative documentation, the facility was required to make available to the public an annual report as of December 31, 2007. The facility failed to document that the annual report was made available to the general public within six months of the end of the fiscal year.
Findings:
Documentation in the administration records indicates the annual report was not made available to the general public until February 27, 2008.
|
Plan of Correction
Within 30 days, Coordinator will meet with Director to review timeliness of notifying the public of annual report within 6 months of the end of the fiscal year. The annual report will be made available to the public annually within six months of the end of the fiscal year, responsibility of Director and Coordinator. New options to be investigated is displaying notification on agency website or continued newspaper announcement. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of six client records and a staff interview, the facility failed to document a complete aftercare plan for three of three client records in which an aftercare plan was required.
Finding:
The aftercare plans did not include a timeframe for the treatment plan goals in client records #4, 5, and 6.
|
Plan of Correction
Within 60 days, Coordinator shall meet with Outpatient Staff to discuss Aftercare Plan. Aftercare Plan to include timeframes for aftercare goals. A new form will be developed to indicate change and presented to and reviewed by staff at next Case Conference on October 17, 2008. Coordinator shall ensure afterplan form is completed correctly through monthly chart reviews. |