INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on May 4, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Oil Region Recovery, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to document that counselors received STD/TB training within the first year, in one of one personnel record.
Employee # 3 was hired as a counselor on August 16, 2018. The STD/TB training was due to be completed by August 16, 2019. There was no documentation that the training had been completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will be required to schedule and complete the mandatory trainings. The employee that needs the training had the required course. The clinical supervisor has started a training manual/log, which will keep track of each employees training hours. Employees certificate from each training will be copied kept in the training manual/log. The clinical supervisor will review the manual quarterly with each counselor. These review session will be logged and kept in the employees training file. This training log will help to ensure this problem will not happen in the future. |
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 an annual financial audit.
The annual financial audit documentation for the 2018/2019 fiscal year was reviewed. The information presented was a review and not an audit.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility director has forwarded policy 709.25 to the facility's accountant. The facilities accountant has contracted with a CPA to complete the 2018/2019 audit by Aug 1st. This agency will complete Oil Region Recovery audit yearly. The facility director will be responsible for communicating with the CPA to ensure a yearly audit will be completed. |