INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the March 29, 2011 licensure renewal inspection. The follow-up inspection was conducted on August 18, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Centre Counseling Associates 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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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of the facility's administrative material, the facility's sole proprietor was unable to provide a copy of the written agreement, with a licensed hospital or physician, for 24 hour emergency psychiatric and medical coverage.
The findings include:
A plan of correction follow up inspection was conducted on August 18, 2011. The sole proprietor was asked to provide a copy of the written agreement for 24 hour emergency psychiatric and medical coverage. The sole proprietor could not provide a copy of the agreement.
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Plan of Correction
The project drector has contacted Mt. Nittany Medical Center several times requesting this document. He has recontacted MNMC on 9/20/2011 and was assurred that the docment will be sent to the facility office by 9/29/2011. The project director will travel to the hospital if necessary to obtain the document in a timely manner. |
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 the facility's administrative materials, the facility's sole proprietor failed to provide a copy of the annual audit for the fiscal year January 1, 2009 through to December 31, 2009.
The findings include:
A plan of correction follow up inspection was conducted on August 18, 2011. The sole proprietor was asked to provide a copy of the annual audit for the fiscal year ended December 31, 2009. The sole proprietor indicated that there was no audit for 2009.
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Plan of Correction
A letter to the appropriate authority requesting a waiver from the need to have an annual audit because of several qualifying issues has been sent to the appropriate office in Harrisburg. |
709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
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Observations
Based on a review of the facility's policy and procedure regarding client rights, the facility failed to provide a procedure describing how portions of the record will be removed prior to a review by the client.
The findings include:
A plan of correction follow up inspection was conducted on August 18, 2011. The policy and procedure on client rights was reviewed. The procedure for removing portions of the client's file prior to the review of the file by the client was not included. The sole proprietor was not able to provide a copy of that procedure.
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Plan of Correction
The requested document was prepared at the time of the inspection but had been misplaced in another file. This procedure document shall be included within the P&P Manual at the time of the 9/29/11 inspection. |