Observations
Based on a review of administrative documentation, the facility failed to make available to the public an annual report.
The findings include:
On January 10, 2014, the facility's administrative documentation was reviewed.
The 2012 annual report was provided and reviewed during the inspection; however, the facility failed to provide documentation verifying that the annual report was made available to the public.
The Project Director confirmed the findings.
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Plan of Correction
Following the inspection, Executive Director and Clinical Supervisor met to discuss a new procedure for making TREHAB's Drug and Alcohol Services Annual Report readily accessible to the public. It was decided the annual report will be uploaded to TREHAB's website with a link provided on the home page for individuals to click and access the report. Additionally, for individuals who do not have access to the internet (we are a rural community with a high concentration of elderly population)TREHAB will place an add in the local newspaper, the Susquehanna County Independent notifying individuals the report is available on the website and upon request. Additionally, both of these avenues will provide documentation for future inspections that the report is indeed available to the public. |