INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 1-2, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Turning Point II, 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and an interview with the project/facility director and the administrative manager, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel record.The findings include:Three personnel records were reviewed on August 1-2, 2011. One personnel record pertained to counselors. One personnel record required the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 3.Employee # 3 was hired on May 5, 2010. The facility training year is from July through June. Employee # 3 had 0 hours of documented training hours for the annual training year from July 2010 through June 2011.The project/facility director and the administrative manager were interviewed on August 2, 2011 at approximately 3:02 PM and confirmed that employee # 3 did not have any documented clock hours of annual training from July 2010 through June 2011.
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Plan of Correction
Employee # 3 did not receive the required training due to a reduction in scheduled work hours and the necessity to complete 30.5 training hours as mandated by their primary employer during the 2010-2011 training year. The Project/Facility Director shall schedule 25 clock hours of approved training for this individual for the 2011-2012 training year. Training requirement will be completed by 6/30/2012. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the 2009/2010 annual report and an interview with the administrative officer, the governing body failed to make available to the public an annual report which included a financial statement of income and expenses, as required by regulation.The findings include:The 2009/2010 annual report was reviewed on August 1, 2011. The facility is publicly funded and required by regulation to make available to the public an annual report which includes a financial statement of income and expenses. On July 16, 2010, the facility made available to the public the 2009/2010 annual report. The 2009/2010 annual report did not include a financial statement of income and expenses. On July 1, 2011 at approximately 3:02 PM, the administrative officer was interviewed. The administrative officer confirmed that a financial statement of income and expenses had not been included in the annual report.
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Plan of Correction
A statement of Income and Expense was inadvertently excluded from the Annual Report for the 2010-2011 program year. The 2010-2011 Annual Report has been revised and a statement of Income and Expense has been added. The 2011-2012 Annual Report and future Reports shall include a statement of Income and Expense. Project Director will oversee the composition and publication of the 2012 Annual Report in July 2012 to insure the inclusion of this item. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of administrative policies and procedures and Board meeting minutes, the project failed to document that the project director assisted the governing body in formulating 2011/2012 project goals and objectives. The findings were:The administrative policies and procedures and Board meeting minutes were reviewed on August 1-2, 2011. There was no documentation that the governing body had assisted in the formulation of the policies and procedures for the 2011/2012 project goals and objectives.An interview with the project/facility director on August 2, 2011 at approximately 3:02 PM confirmed there was no documentation that the governing body had assisted in the formulation of the policies and procedures for the 2011/2012 project goals and objectives.
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Plan of Correction
Evidence of Board review and formulation input of Administrative Policies and Procedures and the Project's Goals and Objectives was unintentionally not documented. The Review and Formulation process for the 2011/2012 Goals and Objectives shall be documented at the next Board meeting. Project/Facility Director shall oversee that future reviews and appropriate documentation occur in a timely manner for the 2012-2013 program year. |
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.
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Observations
Based on a review of administrative policies and procedures, the 2008/2009 audit and interviews with the project/facility director and administrative manager, the project failed to complete the 2009/2010 audit by the end of the project's fiscal year, as required by regulation.The findings include:A review of administrative policies and procedures and the 2008/2009 audit was conducted on August 1, 2011. Per regulation, 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. The project's fiscal year is from July 1 through June 30. The project's audit for July 2009 through June 2010 was due to be completed no later than December 2010. The project failed to document the completion of an annual audit for the 2009/2010 fiscal year. The last audit completed was for the 2008/2009 fiscal year.On August 2, 2011 at approximately 10:05 AM, the project/facility director and the administrative officer were interviewed. They confirmed the 2009/2010 audit had not been completed. They stated they had been advised by their accountant that no audit was necessary due to the program's financial status.
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Plan of Correction
Facility erroneously complied with the directive published in the Bureau of Drug and Alcohol Programs 2005 Fiscal Manual @ para. 9.03 which indicates that no audit was required for Non-Governmental/Non-Profit Organizations expending less than $300,000 in state funds. Annual Audit of the 2009/2010 Program Year will be completed by December 31, 2011. For the 2010-2011 Program Year ending June 30, 2011, the Project/ Facility Director shall oversee the completion of the mandated Annual Audit by December 31, 2011. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on the review of personnel records and interview with the administrative manger, the facility failed to document that individual staff performances were evaluated at least annually in one of three personnel records. The findings include:Three personnel records were reviewed on August 1-2, 2011. Three personnel records required an annual evaluation. Per agency policy, annual evaluations are to be completed on the employee's anniversary date. There was no documentation that an annual evaluation was completed for employee #3. Employee #3 was hired on May 10, 2010. The employees annual evaluation was due to be completed by May 10, 2011. There was no annual evaluation documented. An interview with administrative manager occurred on August 2, 2011 at approximately 3:02 PM. The administrative manager confirmed the annual evaluation was not completed.
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Plan of Correction
Employee # 3 did not receive an Annual Evaluation due to a reduction in scheduled work hours during the 2010-2011 program year. Project/Facility Director conducted an Employee Evaluation 8/12/2011 for the 2010-2011 program year to correct this oversight. Future Employee Annual Evaluations shall be done in a timely manner. |