This report is a result of an onsite follow-up inspection regarding the plans of correction for the December 16, 2009 licensure renewal inspection. The follow-up inspection was conducted on June 4, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Drug and Alcohol Services of Beaver Valley, 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 and a plan of correction is due on July 5, 2010.
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Plan of Correction
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Observations
Based on a review of the fiscal audit for July 1, 2007 through June 30, 2008, the project failed to complete the fiscal audit, as stated in the policy and procedure manual, by the end of the project's fiscal year.
The findings include:
A review of the annual audit was conducted on December 14, 2009. The project's audit for July 1, 2007 through June 30, 2008 was due to be completed no later than December 30, 2008. The project's audit was not completed until May 1, 2009.
Compliance is unable to be determined at this time as the current fiscal year is not complete until June 30, 2010. The facility should re-submit the original plan of correction.
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Plan of Correction
In order to correct this deficiency the Executive Director will contact the accounting firm and inform them that our annual audit will need to be scheduled in July instead of Novemer. This audit was completed June 30, 2008. Contact will be made by December 31, 2009. The Executive Director is responsible for contacting the auditors and scheduling the annual audit. |
Observations
Based on a review of client records and an interview with the facility director, the facility failed to document treatment plan review and updates within sixty days, in five of twenty client records.
The findings include:
Twenty one client records were reviewed on June 4, 2010. Twenty client records required treatment plan review and updates. Per the facility policy, treatment plan review and updates are required to be completed every sixty days. The facility failed to document treatment plan review and updates within sixty days, in client records # 4, 5, 8, 12 and 14.
In client record # 4, the client was admitted on February 23, 2010. The comprehensive treatment plan was completed on March 2, 2010. The first treatment plan update was due no later than May 2, 2010. There was no documentation of a treatment plan review and update in client record # 4 as of June 4, 2010.
In client record # 5, the client was admitted on February 26, 2010. The comprehensive treatment plan was completed on March 4, 2010. The first treatment plan update was due no later than May 4, 2010. There was no documentation of a treatment plan review and update in client record # 5 as of June 4, 2010.
In client record # 8, the client was admitted on March 29, 2010. The comprehensive treatment plan was completed on March 29, 2010. The first treatment plan update was due no later than May 29, 2010. There was no documentation of a treatment plan review and update in client record # 8 as of June 4, 2010.
In client record # 12, the client was admitted on February 2, 2010. The comprehensive treatment plan was completed on March 24, 2010. The first treatment plan update was due no later than May 24, 2010. There was no documentation of a treatment plan review and update in client record # 12 as of June 4, 2010.
In client record # 14, the client was admitted on February 24, 2010. The comprehensive treatment plan was completed on March 17, 2010. The first treatment plan update was due no later than May 17, 2010. There was no documentation of a treatment plan review and update in client record # 12 as of June 4, 2010.
The facility director confirmed on June 4, 2010 that the treatment plan updates were not completed within the 60 day timeframe in all of the aforementioned client records.
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Plan of Correction
The results of the on-site follow-up inspection were shared with all the staff.
Counselors will submit, to the Clinical Supervisor, their plan to monitor treatment plan updates within each chart. Plans are due to the Clinical Supervisor by June 23, 2010.
For the next three months,July, August,and September, both the Clnical Supervisor and the Executive Director will pull 12 charts each month (a total of 24 charts) to review the treatment plan updates. We will document this activity on the Record of Services Form in each chart, as well as keep a copy of this form in the office of the clinical supervisor.
Treatment Plan Updates will continue to be given priority in the on-going case reviews completed by the Clinical Supervior. |