INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the March 1 - 2, 2011 licensure renewal inspection. The follow-up inspection was conducted on December 21, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Freedom Healthcare Services, LLC 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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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on an interview with the project director, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24 hour emergency psychiatric coverage.
The findings include:
The project director was interviewed during a plan of correction follow-up inspection on December 21, 2011, at approximately 10:30 AM. The project director confirmed the facility still has not obtained a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric coverage.
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Plan of Correction
The President/Project Director shall be responsible for securing a psychiatric referral agreement. This agreement will remain in effect until either party cancels the agreement.
If the agreement is canceled, the President/Project Director shall be responsible for securing a new agreement within 30 days of the date of cancellation of the existing agreement.
A current referral agreement will be in place no later than March 1, 2012 |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) 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.
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Observations
Based on an interview with the project director, the project failed to complete an annual audit by fiscal year end, December 31, 2009 and December 31, 2010.
The findings include:
The project director was interviewed during a plan of correction follow-up inspection on December 21, 2011 at approximately 10:30 AM. The project's fiscal year is from January through December. The project director confirmed that a fiscal audit for 2009 and 2010 has not been completed by the project, as of December 21, 2011.
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Plan of Correction
Freedom Healthcare will have an independent fiscal audit for fiscal year(s) 2009, 2010 and 2011 completed by June 30 2012.
The President/Project Director shall be responsible for having this completed by June 30 , 2012.
The outside independent firm shall or other accounting firm shall do an independent audit as required in the future. The President/Project Director shall insure that this is completed on an annual or as required basis, whichever is less frequent. |
709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
Based on a review of administrative documentation, the facility failed to document an informed and voluntary consent or a qualified service organization agreement when releasing urine samples to an outside agency for drug testing.
The findings include:
Consents to release information and qualified service organization agreements were reviewed on December 21, 2011. The project director was interviewed on December 21, 2011 at approximately 11:00 AM and confirmed the facility had not obtained a qualified service organization agreement with the outside agency that conducts drug testing. The project director also confirmed that informed and voluntary consents had not been signed by any of the clients prior to releasing their urine samples to this outside agency.
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Plan of Correction
All patients shall have a voluntary consent form releasing urine samples to an outside agency in their chart no later than March 1, 2012.
A new consent was developed as of Decmeber 21, 2011. Staff has been trained on how to use this consent.
The Clinical Director will delegate this responsibility to each counselor and the counselor will be responsible for making certain that the signed consent is in each patient's chart.
The clinical director will perform client record audits on a consistent basis to ensure this deficiency does not recur.
The consent form shall be added to the intake packet and signed by the patient as part of the intake process. This will insure that a QSOA for our drug testing lab is part of all charts. |