INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6-9, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System -Return Program 1&2 was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility
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Plan of Correction
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) 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, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review administration paperwork on February 9, 2018, the project failed to provide a copy of their annual report. The 2016 annual report was requested.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon emergence for Bankruptcy NPHS will complete an annual report- the first report will cover FY 7-1-2017 thru 6-30-2018. The Sr. Vice President and CEO will ensure that annual reports are completed on or before September 30th of each year.
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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 administration paperwork on February 9, 2018, the project failed to provide a copy of their annual audit. The 2016 annual audit was requested.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon emergence from Bankruptcy NPHS will complete its annual audit and file a copy with DDAP. The CEO/Sr. Vice President will ensure that the audit is done on an annual basis. |