Observations
Based on a review of administrative materials and an interview with the facility director, the facility failed to document an audit for the fiscal year ended December 31, 2009.
The findings include:
Per regulation, the project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project's fiscal year is January through December. The facility director was not able to provide a copy of an annual audit for the 2009 fiscal year during the inspection conducted from November 8 - 10, 2010. The facility director confirmed that an audit for the 2009 fiscal year had not been completed.
This is a repeat citation.
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Plan of Correction
Discovery House will conduct an audit for fiscal year 2010. We will submit a 2009 compellation review and an engagement letter for 2010. Program Director will be charged to ensure this task is completed. |
Observations
Based on a review of client records, and an interview with the facility director, the facility failed to provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plans, in ten of seventeen client records.
The findings include:
Twenty-six client records were reviewed on November 8 - 10, 2010. Per regulation, an individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of the proposed type of support service.
The individual treatment and rehabilitation plans were required to document proposed type of support services in seventeen client records. Nine client records were from a time frame outside of the current licensing inspection. The facility did not document proposed type of support services on the treatment plans in client records # 1, 2, 3, 5, 6, 16, 17, 18, 19 and 20.
Client # 1 was admitted into treatment on March 3, 2010. The individual treatment and rehabilitation plan was completed on April 19, 2010. There was no documentation of support services in the treatment plan.
Client # 2 was admitted into treatment on January 26, 2010. The individual treatment and rehabilitation plan was completed on February 24, 2010. There was no documentation of support services in the treatment plan.
Client # 3 was admitted into treatment on March 30, 2010. The individual treatment and rehabilitation plan was completed on April 30, 2010. There was no documentation of support services in the treatment plan.
Client # 5 was admitted into treatment on April 28, 2010. The individual treatment and rehabilitation plan was completed on May 28, 2010. There was no documentation of support services in the treatment plan.
Client # 6 was admitted into treatment on January 28, 2010. The individual treatment and rehabilitation plan was completed on February 18, 2010. There was no documentation of support services in the treatment plan.
Client # 16 was admitted into treatment on September 23, 2010. The individual treatment and rehabilitation plan was completed on October 22, 2010. There was no documentation of support services in the treatment plan.
Client # 17 was admitted into treatment on May 20, 2010. The individual treatment and rehabilitation plan was completed on June 11, 2010. There was no documentation of support services in the treatment plan.
Client # 18 was admitted into treatment on May 21, 2010. The individual treatment and rehabilitation plan was completed on June 22, 2010. There was no documentation of support services in the treatment plan.
Client # 19 was admitted into treatment on May 28, 2010. The individual treatment and rehabilitation plan was completed on June 16, 2010. There was no documentation of support services in the treatment plan.
Client # 20 was admitted into treatment on May 25, 2010. The individual treatment and rehabilitation plan was completed on June 28, 2010. There was no documentation of support services in the treatment plan.
On November 9 - 10, 2010 the facility director reviewed these client records and confirmed that support services were not included on the individual treatment plans.
This is a repeat citation.
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Plan of Correction
The finding that Discovery House failed to provide written documentation of proposed support services in first comprehensive treatment plans was reviewed with Clinical Team on 11/17/2010.
The counselors are charged to incorporate types of support services in the patient's first and subsequent comprehensive treatment plans.
Clinical Supervisors will review each treatment plan and will only approve treatment plans submitted that contain support services. Treatment plans not approved will require counselors to re-evaluate treatment plan to incorporate support services.
Program Director will perform spot audits to ensure Discovery House is in compliance of this regulation. |