INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18-19, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Casa de Consejeria y Salud Integral 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(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 a review of administrative documentation, the facility failed to document an annual audit of financial activities associated with the project's drug/alcohol abuse services by the end of the 2012/2013 fiscal year.The findings include:The facility's fiscal year runs from July 1 through June 30. The project's administrative materials were reviewed on August 18, 2014. A copy of the annual financial audit for the 2012/2013 fiscal year was requested. The facility failed to present a financial audit for the 2012/2013 fiscal year. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director along with the Project Director will closely work with organization's CPA in order to complete the 2013 Financial Audit by no later than November 30, 2014. In order to prevent this from happening in the following years. Monthly alerts will be set to follow up with the CPA and ensure the accuracy of our audit. The alert system will be set through our internal communication network and set up no later than November 30, 2014 as well. |
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 the review of client records, the facility failed to document a complete client record to include consent forms and a record of services in three out of eight client records.The findings include:Consent to drug and alcohol treatment must be signed by the client prior to the start of treatment. Eight client records requiring documentation of consent to treatment and a record of services were reviewed on August 18-19, 2014. The facility failed to document consent to treatment in client records # 5 and 7; and client record # 3 did not include a record of services. Client #5 was admitted to treatment on March 19, 2014 and discharged on July 2, 2014. As of the date of inspection, there was no documentation of consent to drug and alcohol treatment for client # 5. Client #7 was admitted to treatment on December 21, 2013 and discharged on March 24, 2014. As of the date of inspection, there was no documentation of consent to drug and alcohol treatment for client # 7. Client #3 was admitted to treatment on June 10, 2014 and still active at the date of inspection. Client record #3 did not include a record of services provided. The findings were reviewed with facility staff during the inspection process.
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Plan of Correction
The consent of treatment is currently part of the admission/intake process. However, the cases reviewed were for many individuals that were readmitted into the program and the consent to treatment was not updated properly. The facility director will complete two one hour trainings that will review the initial admission/intake process as well as the readmission process for any clients that return to treatment within the next 6 months after their discharge date. This training would focus and refresh counselors on all the documents that must be reviewed and completed during any type of admission with a specific focus on the consent to treatment. These trainings will also provide information on the clinical documents that must also be completed within the first 30 days of a client's admission or readmission into treatment. We will prevent future mistakes by following up individually with each counselor during their weekly supervision meetings with the facility director. This will be completed no later than 11/30/14 |