INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 1, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Central Outreach Resource and Referral Center 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to document unannounced fire drills at least once a month. The fire drill logs were reviewed for the period of November 2019 to September 2020. There was no documentation that fire drills were completed in July, August and September 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
Central Outreach Center has created the following plan of correction to deficiencies705.28 found during a site licensure renewal inspection conducted on 10/12/2020
The Program Director will ensure that fire drills take place during normal staffing conditions
To ensure that this does not recur, the Program Director will review fire drill log book monthly and the office Secretary and a board member to ensure that fire drill are being completed monthly Therefore, meeting DDAP requirements as stated in the DDAP Licensure regulations.
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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
The facility failed to obtain the services of an independent certified public accountant for an annual financial audit. There was no documentation that an annual financial audit was completed for the year 2019. There was no documentation that an exception had been requested or approved. These finding were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.25 found doing a site Licensure renewal inspection conducted on 10/1/2020
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 .
the Executive Director shell ensuring the corrective action(s) is implemented.
the executive Director if needed
shell develops and implement request for the audit exception |