Observations
Based on a review of administrative paperwork submitted by the facility and discussion with the facility director, the facility failed to 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.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility makes less than $500,000. per fiscal year, and request for exception of 28 Pa. Code §709.25(a) Fiscal management annual audits was sent; and exception of 28 Pa. Code §709.25(a) Fiscal management annual audits was approved on 5/13/2022. |
Observations
Based on a review of four client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the four client records reviewed, in writing that included, the name of the person, agency or organization to whom disclosure is made.
Client #1 was admitted on February 17, 2022 and discharged on April 21, 2022. An informed and voluntary consent from the client for the disclosure of information signed and dated by the client on February 17, 2022, did not include a specific person, agency or organization to whom disclosure is made. The consent form for funding listed multiple funding sources beyond the client ' s identified funding source.
Client #2 was admitted on August 4, 2021 and discharged on September 8, 2021. An informed and voluntary consent from the client for the disclosure of information signed and dated by the client on August 4, 2021, did not include a specific person, agency or organization to whom disclosure is made. The consent form for funding listed multiple funding sources beyond the client ' s identified funding source.
Client #3 was admitted on March 21, 2022 and discharged on May 6, 2022. An informed and voluntary consent from the client for the disclosure of information signed and dated by the client on March 21, 2022, did not include a specific person, agency or organization to whom disclosure is made. The consent form for funding listed multiple funding sources beyond the client ' s identified funding source.
Client #4 was admitted on July 23, 2021 and was current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated by the client on July 23, 2021, did not include a specific person, agency or organization to whom disclosure is made. The consent form for funding listed multiple funding sources beyond the client ' s identified funding source.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will ensure that each client's consent form for funding sources will only list specific person, agency or organization to who disclosure is made; and the project director will ensure that each client's consent form for funding will only list client's identified funding source effective today (on 05/13/2022).
The project director will ensure that when client attends next appointment, active client's funding consent will be updated; and Client's updated funding consent form on client's record for funding sources will only list specific person, agency or organization to who disclosure is made; and the project director will ensure that active client's consent form for funding will only list client's identified funding source effective today (on 05/13/2022) |