INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 30, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, TW Ponessa and Associates Counseling Services, 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 and a plan of correction is due on August 27, 2010.
|
Plan of Correction
|
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.
|
Observations
Based on a review of administrative documentation during the onsite inspection, the annual audit for the fiscal year reviewed was not completed.
The findings include:
The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the projects drug/alcohol abuse services. The facility failed to obtain an annual audit for the 2008-2009 financial activities.
|
Plan of Correction
Annual Audit for FY 2008-2009 completed on July 31,2010 by independent auditor. The CEO will ensure that an annual audit for the fiscal year (July 1 to June 30) will be completed on a yearly basis and will be available for the annual licensing review. |
704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
|
Observations
Based on the review of the Policy and Procedure Manual, the facility failed to have a policy in place to address relapse of recovering clinical personnel.
The findings include:
A review of facility documentation on July 30, 2010 revealed that the facility failed to maintain a policy to address relapse of a recovering clinical personnel.
|
Plan of Correction
9-2-10 The Facility Director will ensure that the policy to address recovering personnel, which is currently included in the D&A Policy and Procedure Manual as the Drug-Free Workplace Policy is referenced and listed as policy # 704.3. The Facility Director will ensure that the Facility Director, CEO, and owner of TW Ponessa will review and update the D&A Policy and Procedure Manual annually. |
704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
|
Observations
Based on a review of the agency policy manual during the onsite licensing inspection , the facility failed to meet the requirement to address the recruitment and hiring of staff persons
The findings include:
A review of the policy and procedure manual on July 30, 2010 revealed that the facility failed to document a policy and procedure to address the recruitment and hiring of staff persons appropriate to the served population.
|
Plan of Correction
A policy that addresses the recruitment amd hiring of staff persons who are appropriate to the population served will be developed by the Drug and Alcohol Facility Director and added to the T.W. Ponessa and Associates Counseling Services Drug and Alcohol Program Policy and Procedures Manual as policy # 704.3. The policy will also address that every effort will be made to hire staff persons representative of that population. |