INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 21, 2016 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, Inc., 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 administrative documention during the renewal inspection on September 21, 2016, the project failed to obtain the services of an independent public accountant for an annual audit of financial actives associated with the project's drug and alcohol abuse services.The facility's fiscal year runs from January 1 to December 31. The facility did not complete an independent financial audit for the 2015 fiscal year. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has contacted an independent public accountant who will have our 2015 financial audit completed by the date indicated above. The Executive Director will make sure to secure the commencement of the 2016 and future audits no later than May 31 through an engagement letter and completed by June 30. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records on September 21, 2016, the facility failed to document performance evaluations in four personnel records.Employee #1 was hired by the project on 1/23/06 and as the Executive Director on 10/30/2015.Employee #2 was hired by the project on 6/9/2009 and as the Program Director on 10/30/2015.Employee #3 was hired by the project on 6/4/2012 and as the Clinical Supervisor on 7/30/2015.Employee #4 was hired by the project as a Counselor on 6/25/2009. Employee 1 through 4 did not receive an annual written performance evaluation since the calendar year 2014. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director is currently working with all direct supervisors on completing all annual performance evaluations needed for all staff members. The completion of the current evaluations needed will occur by the date indicated above. In order to ensure the assurance of this task, the Executive Director will add this human resource task to an already created personnel spread sheet which tracks updates and actions needed to be taken with deadlines for each employee. Performance evaluations are typically completed based on the anniversary of the employee hire date. This will prevent this oversight from re-occuring. |