INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia 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 documents submitted, the project failed to 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.The project's last annual financial audit was for the years ending June 30, 2020 and 2019. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
§ 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.
The project's last annual financial audit was for the years ending June 30, 2020 and 2019.
These findings were reviewed with the project staff during the licensing process.
The Annual Financial Audit for the most recent fiscal year (FY 2020 ? 2021) was not completed in a timely manner due to the delays on the part of the independent certified public accounting firm.
Among these delays were the application of new standards regarding the review of all leased properties (to include all real estate, business machines, and vehicles). This was a very laborious process that will not need to be repeated in the future.
Gaudenzia will obtain a completed financial audit from the independent certified public accounting firm on or before September 30th of 2022.
In order to help ensure that these delays do not occur in the future, the reorganized Fiscal department will begin preparation of all possible documents required for the audit as early as possible in the year.
Leadership in this department reviewed the regulations in DDAP 709.25 on 4/26/22 in order to ensure that all understand the importance of timely completion of the Financial Audit.
The Chief Financial Officer will oversee this process.
9/30/22
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709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection on April 28, 2022, the facility failed to display the hours of project operation conspicuously to the general public. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hours/Emergency Phone Number
Due to ongoing construction at the facility, the posting displaying the Hours and Emergency Phone number was moved by the contractor. It has seen been replaced at the entrance to the facility on 4/29/22.
This will be monitored during regular monthly safety inspections at the program, which are documented on a standard form. The Program Director will review the results of these inspections each month.
This will also be monitored during the Quality Assurance department's quarterly reviews which include a physical plant inspection.
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709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection on April 28, 2022, the facility failed to display a telephone number conspicuously to the general public for emergency purposes.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hours/Emergency Phone Number
Due to ongoing construction at the facility, the posting displaying the Hours and Emergency Phone number was moved by the contractor. It has seen been replaced at the entrance to the facility on 4/29/22.
This will be monitored during regular monthly safety inspections at the program, which are documented on a standard form. The Program Director will review the results of these inspections each month.
This will also be monitored during the Quality Assurance department's quarterly reviews which include a physical plant inspection.
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709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection on April 28, 2022, the facility failed to display the hours of project operation conspicuously to the general public. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hours/Emergency Phone Number
Due to ongoing construction at the facility, the posting displaying the Hours and Emergency Phone number was moved by the contractor. It has seen been replaced at the entrance to the facility on 4/29/22.
This will be monitored during regular monthly safety inspections at the program, which are documented on a standard form. The Program Director will review the results of these inspections each month.
This will also be monitored during the Quality Assurance department's quarterly reviews which include a physical plant inspection.
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709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection on April 28, 2022, the facility failed to display a telephone number conspicuously to the general public for emergency purposes.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hours/Emergency Phone Number
Due to ongoing construction at the facility, the posting displaying the Hours and Emergency Phone number was moved by the contractor. It has seen been replaced at the entrance to the facility on 4/29/22.
This will be monitored during regular monthly safety inspections at the program, which are documented on a standard form. The Program Director will review the results of these inspections each month.
This will also be monitored during the Quality Assurance department's quarterly reviews which include a physical plant inspection.
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