INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7, 2014 and February 10, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, ADAPPT Outpatient Treatment Services 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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705.24 (1) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(1) Provide bathrooms to accommodate staff, clients and other users of the facility.
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Observations
Based on a review of the physical plant, the facility failed to ensure that the water temperature did not exceed 120 degrees.
The findings included:
During the physical plant tour on February 7, 2014, at 11:30 a.m., the water temperature was checked in the women's restroom. The water temperature was tested at 130 degrees.
The findings were confirmed with the staff member providing the tour.
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Plan of Correction
Maintenance personnel shall ensure that periodic checks are done on a daily basis to ensure that water temperatures in all bathrooms do not exceed 120 degrees. |
709.22(e) 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:
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Observations
Based on a review of administrative documentation, the facility failed to include a statement disclosing the names of officers, directors and principal shareholders in the annual report.
The findings included:
The annual report for the 2013 year was reviewed during the renewal process. The annual report failed to include a statement disclosing the names of officers, directors and principal shareholders, where applicable.
The findings were reviewed and confirmed with the facility director.
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Plan of Correction
A statement disclosing the names of officers, directors, and principal shareholders has been added to the 2013 Annual Report.
Going forward the Facility Director shall ensure that this information is included in future annual reports. |
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 documentation, the project failed to 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 findings included:
The facility's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services on February 7, 2014. The facility ' s fiscal year runs from January 1 to December 31.
The facility did not document an independent financial audit for the 2012 fiscal year.
An interview with facility director confirmed the findings.
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Plan of Correction
The Project Director will be responsible for meeting with corporate counsel to ensure that the annual audit of financial activities for the January 2012 through December 2012 fiscal year is completed. The Project Director will follow up annually to ensure that th audit of financial activities is completed and available by June 30th of each year. The Project Director will maintain communication and monitor progress of completed audit with corporate representatives at the beginning of each calendar year and request a completed annual audit of financial activities for the project so that it is available by June 30th. |