INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24, 2021 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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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The facility failed to obtain the services of an independent certified public accountant for an annual financial audit. There was no documentation that an annual financial audit was completed for the year 2020. There was no documentation that an exception had been requested or approved. These finding were reviewed with facility staff during the licensing inspection.This is a repeat deficiency from the October 1, 2020 licensing inspection.
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Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction. found during a site licensure renewal inspection for 709.25 conducted on 09/24/2021
The Executive Director has submitted an exception request in regards to the annual fiscal audit. If this exception request is not approved, the Executive Director will obtain the services of a CPA to complete an annual fiscal audit each year.
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709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent for the disclosure of information contained in the client record in six of seven records.Client records #1, 2, 4, 5, 6 and 7 did not include documentation of signed releases of information, even though assessments and referrals were completed.Client #1 was provided an assessment referral on June 23, 2021. Client #2 was provided an assessment referral on March 12, 2021. Client #4 was provided an assessment referral on February 3, 2021. Client #5 was provided an assessment referral on December 18, 2020. Client #6 was provided an assessment referral on May 24, 2021. Client #7 was provided an assessment referral on April 7, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction. found during a site licensure renewal inspection for 709.43 conducted on 09/24/2021
The Executive Director is presenting Prior to releasing any information from the client record, the client will be required to physically sign a consent to release information. The Executive Director is responsible for implementing this plan of correction and it will be monitored via chart reviews.
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709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to document a written client acknowledgment that they have been notified of client rights in seven of seven client records.Client #1 was provided an assessment/referral on June 23, 2021.Client #2 was provided an assessment/referral on March 12, 2021.Client #3 was provided an assessment/referral on January 7, 2021.Client #4 was provided an assessment/referral on February 3, 2021.Client #5 was provided an assessment/referral on December 18, 2020.Client #6 was provided an assessment/referral on May 24, 2021.Client #7 was provided an assessment/referral on April 7, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction. found during a site licensure renewal inspection for 709.30 conducted on 09/24/2021
The Executive Director is presenting that Each client will be presented with the required client rights and will be required to sign the form acknowledging the receipt of these rights. The Executive Director is responsible for implementing this plan of correction and it will be monitored via chart reviews.
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709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
Based on a review of client records, the facility failed to document a consent to treatment form in six of seven records.Client records #1, 2, 4, 5, 6 and 7 did not include documentation of signed consent to treatment/services, even though assessments and referrals were completed.Client #1 was provided an assessment referral on June 23, 2021. Client #2 was provided an assessment referral on March 12, 2021. Client #4 was provided an assessment referral on February 3, 2021. Client #5 was provided an assessment referral on December 18, 2020. Client #6 was provided an assessment referral on May 24, 2021. Client #7 was provided an assessment referral on April 7, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction. found during a site licensure renewal inspection for 0671 conducted on 09/24/2021
The Executive Director is presenting Prior to intake the Client will be required sign a consent to treatment.
The Executive Director is responsible for implementing this plan of correction and it will be monitored via chart reviews.
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