INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 15 - 16, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Counseling and Adoption 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 and a plan of correction is due on May 15, 2009. .
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Plan of Correction
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative polices and procedures and an interview with the Facility Director, the facility failed to document the annual update of a written manual delineating project polices and procedures.
The findings include:
The administrative policies and procedures were reviewed on April 15, 2009. The project director failed to document the annual update of the written project policies and procedures, as required.
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Plan of Correction
Project Director will sign policies and procedures manaual for 2009 within the next five business days.
Project Director will review policies and procedures manual by the second week of January and sign when review completed. This will begin in Jan 2010. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the administrative policy and procedure manual, the facility failed to document a follow up policy which includes follow up on all clients that have been discharged from the treatment program.
The findings include:
The administrative policies and procedures were reviewed on April 15, 2009. The agency is required to have a follow up policy to include all clients that are discharged from the program. The agency follow up policy addresses clients that are referred to outside sources and clients who have completed treatment. The facility did not document in their follow up policy, clients that failed to complete the treatment program.
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Plan of Correction
Current policy reads:
"When a client has completed treatment, a Follow-up Letter will be mailed by the Office Manager at 3 month intervals for one year after discharge."
Policy will be revised to read:
"All drug and alcohol clients after being discharged from counseling will be mailed a Follow-up Letter by the Office Manager 3 months after discharge." |