INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 10, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Insights II, Inc., was found to be not 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
Based on a review of submitted administrative documents and on-site review of documents conducted on January 10, 2018 the facility failed to obtain the services of an independent certified public account for an annual financial audit for fiscal year July 1, 2016 thru June 30, 2017.
This information was reviewed with facility staff during the licensing process
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Plan of Correction
The President is responsible for the fiscal management aspects of the project. Upon learning of the requirement for an annual audit by an independent public accountant, the President was also informed by the DDAP inspector that if the project nets $500,000.00 or less during the fiscal year, it can apply for an exemption. The President wrote a letter stating that our agency did not net $500,000.00 or more during the last fiscal year and requesting the exemption. This letter was completed and turned in to the inspector on January 9, 2018. The President will be responsible for ensuring that an independent certified public accountant is consulted for an audit yearly. In the event that the agency does not net $500,000.00 in the fiscal year, the President will ensure a letter of exemption is submitted timely to the DDAP inspector prior to the inspection. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Project policy and procedure manual was reviewed on January 9, 2018. The facility policy failed to properly articulate the following elements with regard to client rights:
(3) Facility policy allows the clinician to limit client access to their records.
(5) Facility policy allows for the ' removal of ' instead of the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
This information was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Assistant is responsible for the updating of client forms. The Client Rights form was edited on January 17, 2018, by the Executive Assistant to reflect that only the project, facility, or clinical director, not clinician, can limit client access to their file by removing portions they feel will be detrimental to the client if presented. The updated Client Rights policy also stipulates that a reason will be given for any portion of the file that is redacted by the director. Also edited on the Client Rights policy and procedure was the verbiage "removal of" pertaining to information in the client's record. This was changed to reflect that "clients have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records." The updated Client Rights forms were distributed to staff on January 17 and the front desk staff was instructed to replace any outdated forms not in use with the updated one. The Project Director formally announced the updating of the Client Rights form in staff meeting on January 18, 2018. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Seven partial hospitalization client records were reviewed on January 10, 2018; the facility failed to specify the type and frequency of treatment on the Master Treatment Plan in client records, #3, 4, 5 & 6.
Client #3 was admitted on 12/26/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan was documented on 1/3/18.
Client #4 was admitted on 3/20/17 and discharged on 4/18/17. The comprehensive treatment plan was documented on 3/31/17.
Client #5 was admitted on 9/29/17 and discharged on 10/28/17. The comprehensive treatment plan was documented on 10/9/17.
Client #6 was admitted on 7/14/17 and discharged on 8/4/17. The comprehensive treatment plan was documented on 7/27/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The counselors were instructed in a staff meeting on January 18, 2018, by the Project Director, to provide the type and frequency on all treatment plans for the number of groups and individual weekly sessions that a client attends. This information will also be integrated into our new hire training packet as well. The Project Director and Office managers will be responsible to monitor this action through ongoing and random quality assurance. |