INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26-27,2010 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 24, 2010.
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Plan of Correction
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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 materials during the onsite inspection, the facility failed to obtain an independent public accountant to have an annual audit for the fiscal year reviewed.
The findings include:
A review of the Policy and Procedure Manual and an interview with the CEO and project director at 10:00 A.M. July 27, 2010, confirmed that the facility failed to obtain an annual audit for the 2008-2009 fiscal year.
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Plan of Correction
Annual Audit for FY 2008-2009 completed on July 31,2010 by independent auditor.
The TW Ponessa 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. |
705.28 (c) (2) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to maintain a portable fire extinguisher with a minimum of an ABC rating as required.
The findings include:
A physical plant inspection was conducted with the facility director on July 27, 2010 from 2:30 PM until 3:00 PM. Per regulation, the nonresidential facility shall maintain a portable fire extinguisher with a minimum of an ABC rating in each kitchen area. The facility director confirmed that there was not a portable fire extinguisher located within the kitchen area of the facility.
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Plan of Correction
Portable fire extinguisher with ABC rating installed 08/24/2010 inside kitchen area to the left of the entrance. The TW Ponessa facility manager will ensure that the fire extinguishers are in place and are maintained by the contracted fire safety company. |
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.
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Observations
Based on a review of the policy manual the facility failed to have a written policy in place to address recovering clinical personnel.
The findings include:
A review of the policy manual on July 27, 2010 and an interview with the project director, confirmed that the facility failed to address the relapse of recovering clinical personnel.
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Plan of Correction
The Drug and Alcohol Facility Director will ensure that the policy to address recovering clinical personel 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 Drug and Alcohol Facility Director, the TW Ponessa CEO, and the owner of TW Ponessa will review and update the Drug and Alcohol 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.
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Observations
Based on a review of the agency policy manual, the facility failed to document a recruitment policy.
The findings include:
A review of the policy manual on July 27, 2010 revealed that the project failed to develop a policy that addressed the recruitment and hiring of staff persons who are appropriate to the population to be served.
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Plan of Correction
A policy that addresses the recruitment and 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 Procedure Manual as policy # 704.3 The policy will also address that every effort will be made to hire staff persons representative of that population. |