INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Brookdale 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection on June 8, 2021 the facility failed to ensure that counseling sessions could not be seen or heard from outside the counseling area as group rooms 1, 3 and 4 all had session being conducted while the blinds were open.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Specific Course of Action: Brookdale will ensure that blinds will be closed during group sessions.
Means: Clinical staff will be educated on the importance of privacy during counseling sessions and to keep the blinds closed at all times.
Responsible Parties: The Senior Clinical Director or the Chief Compliance Officer will monitor the counseling sessions weekly to ensure blinds are closed.
Facility will be in full compliance on 6/29/2021 |
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 discussion with facility staff, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the projects drug and alcohol abuse services.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Specific Course of Action: Brookdale will obtain the services of an independent certified public accountant to perform an audit.
Means: The CFO will begin interviewing potential CPA's for conducting the required annual audit of Brookdale's financial activities. The fiscal audit will be scheduled as soon as possible in order to get into compliance with this standard.
Responsible Parties: The Chief Financial Officer will ensure an audit is completed annually.
Facility will be in full compliance on 12/31/2021 |