INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 14, 2010 through June 15, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Family House 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 12, 2010.
|
Plan of Correction
|
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.
|
Observations
Based on the review of the facility's policy and procedure manual, the facility failed to complete an annual audit by the end of the facility's fiscal year, ending June 30, 2009.
The findings include:
The policy and procedure manual was reviewed on June 7, 2010. The annual audit was not made available until June 6, 2010. The documentation was required to be made available prior to the end of their 2009 fiscal year which ended June 30, 2009.
|
Plan of Correction
The Annual Audit will be made available prior to the end of the Fiscal year ending on June 30th of that year. If for some unforseen circumstance the audit will not be made available by that date a request for an extension will be submitted.
Central Office personnel will be responsible for implementing this correction immediately. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to completely document psychosocial evaluations in six of six client records reviewed.
The finding includes:
Eight records were reviewed on June 15, 2010. Psychosocial evaluations were required in Eight records reviewed.
Client records #1 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and client's attitude towards treatment.
Client records #2, 3 and 6 failed to document the client's assets/strengths, support systems,coping mechanisms and negative factors that might inhibit treatment.
Client records #3 and 5 failed to document the client's assets/strengths, coping mechanisms and negative factors that might inhibit treatment.
|
Plan of Correction
Clinical staff will be re-trained on completing psychosocial evaluations by June 30, 2010.
Program Director and designee will review and sign all psychosocial evaluations to ensure that they are completely filled out. This action will begin as of June 29, 2010.
Program will use updated psychosocial evaluation to ensure that all documentation requirements are met. This action will begin as of June 29, 2010. |