INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 19 -20, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Genesis House Ministries, 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:
|
Plan of Correction
|
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every six months. Based on the facility program schedule, lights out is at 11pm and wake up is at 7am. During the previous inspection on April 10, 2024 the fire drills from December 2023 to March 2024 were reviewed. There was an overnight drill conducted on December 13, 2023. During the current inspection on December 19-20, 2024, the fire drills from March 2024 to current, December 2024 were reviewed. There was an overnight drill conducted on November 26, 2024. The finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
In a meeting on 12/20/2024 it was determined that we would hold a nighttime fire drill during sleeping hours beginning 12/24.
Admin staff will be responsible for setting a 6-month reminder for all sleeping hour fire drills as not to miss any. CFO along with administration will be responsible for monthly checks of fire drill log to ensure all 6-month fire drills were completed during sleeping hours. |
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.
|
Observations
Based on a review of administrative information, the facility failed to provide an annual financial audit for the fiscal year July 1, 2022 to June 30, 2023. An exception for completing the financial audit was granted on February 13, 2023, but the facility exceeded the parameters outlined in the exception approval.The findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
In a meeting on 12/20/2024 it was determined that a Certified Public accountant would be set in place to do a financial audit for the fiscal year July 1, 2022 to June 30, 2023 and additionally be set in place to do annual audits as needed per year.
We are pending agreement to have this completed by March 30, 2024.
The Financial Director and CFO will be responsible for making sure the audits are completed. |