INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 30, 2019 through October 31, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Spring-Ford Counseling Services, Inc. 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 project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director has reported and received approval from Board of Directors to submit a request for exception for 28 Pa Code 709.25 (a). Exception request has been submitted to Division of D/A Programs.
If exception is not granted by PA State, SFCS will complete an audit for 2019-2020 (current) fiscal year. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to ensure that employee #1 had reviewed and signed an annual written individual performance evaluation for the period reviewed. The employee's 2018 performance evaluation was completed and signed by the evaluator on July 31, 2018, but was not signed or acknowledged by the employee as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 has reviewed and signed performance evaluation dated July 31, 2018. Executive Director will ensure that all performance evaluations are signed by evaluators and staff by reviewing evaluations during month of July - beginning of SFCS fiscal year. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of disclosure on a release of information form in one of nine client records reviewed.
Client #2 was admitted on December 10, 2018 and was still active at the time of the inspection. A release of information form to a government agency was signed and dated on November 7, 2018.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By December 1, 2019, Client #2 will sign an new release of information which includes purpose. By December 1, 2019 Executive Director will notify/review with DAT Treatment staff completion standards of consents to release information. Executive Director will follow through with chart reviews once per month to ensure compliance. |
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
The facility failed to provide documentation that verified that the client had given written acknowledgement that they had been informed that when they shall retain all their civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment in every client record reviewed.
Client #1 was admitted on September 27, 2019 and was still active at the time of the inspection.
Client #2 was admitted on December 10, 2018 and was still active at the time of the inspection.
Client #3 was admitted on October 15, 2019 and was still active at the time of the inspection.
Client #4 was admitted on July 24, 2017 and was discharged on April 16, 2018.
Client #5 was admitted on August 9, 2018 and was discharged on November 13, 2018.
Client #6 was admitted on July 21, 2019 and was discharged on September 5, 2019.
Client #7 was admitted on January 9, 2019 and was discharged on April 17, 2019.
Client #8 was admitted on October 16, 2019 and was still active at the time of the inspection.
Client #9 was admitted on May 31, 2019 and was discharged on June 27, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By December 1, 2019, Executive Director shall update Client Bill of Rights and Nondiscrimination of Services to reflect 709.30 (1) - that clients shall retain all their civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment. This update shall be signed by all current clients and new clients. Executive Director shall provide monthly chart reviews to ensure paperwork is up to date and signed. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
The facility failed to include, in their unusual incident policy, specific procedures to follow regarding the prompt review and identification of the causes directly or indirectly responsible for unusual incidents.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director has revised Reporting of Unusual Incidents Policy and Proceedure to include specific procedure for a prompt review and identification of causes directly or indirectly responsible for unusual incidents. Policy and Proceedure will be distributed to Board of Directors for approval before December 13, 2019 per next Board Meeting. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
The facility failed to include, in their unusual incident policy, specific procedures to follow regarding the implementation of a timely and appropriate corrective action plan following an unusual incident.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director has revised Reporting of Unusual Incidents Policy and Proceedure to include specific procedure to implement a timely and appropriate corrective action plan following an unusual incident. Policy and Proceedure will be distributed to Board of Directors for approval before December 13, 2019 per next Board Meeting. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
The facility failed to include, in their unusual incident policy, specific procedures to follow regarding the ongoing monitoring of an unusual incident corrective action plan.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director has revised Reporting of Unusual Incidents Policy and Proceedure to include specific procedure regarding the ongoing monitoring of unusual incident corrective action plan. Policy and Proceedure will be distributed to Board of Directors for approval before December 13, 2019 per next Board Meeting. |