INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 8, 2016 by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Impact Counseling 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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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall 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.
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Observations
Based on a review of presubmission materials supplied by the facility on July 11, 2016 and a conversation with the Project Director conducted on September 8, 2016 the facility failed to submit an annual financial audit or request an exception to the regulation requiring an audit.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The project director will employ 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 will occur when taxes are completed annually. |
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.
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Observations
Based on a review of client records, the facility failed to document a valid consent form in one of ten client records.
Client record #8 contained a consent to release information dated 11/4/15 to a government agency that did not specify the information that was to be released.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The project director will train all staff on the appropriate way a consent is to be filled out and what should be released to person or agency to whom the release is filled out to.
The project director will monitor and audit charts for completion. |
709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on a review of client records conducted on September 8, 2016, the facility failed to ensure that there was a complete client record in three of ten client records.
Client record #3 contained a record of service entry for 7/27/16 however there was no corresponding progress note for that date.
Client record #5 contained a group progress note dated 5/27/16 however this service was listed on the record of service as 5/28/16.
Client #9 was admitted on 12/30/15 and was discharged 5/11/16. Facility failed to document follow up information as of the date of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Project Director will train all staff on compliance of this issue. Staff will mark all progress notes with the date and time of service and these will mirror the record of service. There will also be follow up contact with client 90 days from discharge. proof of this will be kept in the chart. Project Director will monitor all charts for accuracy. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. this will be monitored by management. |