INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 15, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, TPALS Turning Point Alternative Living Solutions 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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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the February 2022 through January 2023 fire drill logs, the facility failed to set off a fire alarm or smoke detector during each fire drill conducted during the reviewed period. For all drills completed, the facility announced the drills by "Ring Bell."
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/20/2023, Clinical Director met with the owner of the building regarding using the fire alarm during the monthly fire drills and discussed the following plan so that TPALS will not use ringing of the bell.
The procedure will go as follows for the remainder of the years...
Staff training will be held on Monday 3/20/2023 to inform all staff of how to transition out of the building upon unannounced fire drill.
Clinical director will conduct an unannounced fire drill once a month. The drill will occur at different times each month and comply with all 709.28 d. standards.
Clinical Director will use only a smoke detector or fire alarm to alert any participants.
To ensure that this does not occur in the future, project director will randomly audit the fire drill documentation to ensure that the drills are meeting regulations. |
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 an administrative review and a review of the project's 2022 federal income tax returns, 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 that included reference to the drug and alcohol treatment activities for the 2022 fiscal year.
The project currently has a DDAP-approved exception for obtaining an annual financial audit; however, per DDAP Licensing Alert 01-11, the DDAP representative was unable to verify, from the income tax returns, the annual gross revenue received from the facility's drug and alcohol activities did not exceed $500,000.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/24/2023, Facility Director and Executive Director conducted a meeting regarding a plan for the financial audit. Executive Director will seek out a CPA and schedule a financial audit for 2022 to be completed by 6/30/2023. TPALS will ensure that 2023's audit will be completed by 6/30/2024. Each year, the audit for the previous year will be completed by 6/30 of the following year.
Tax forms will be available on site to be reviewed when next inspection takes place.
To ensure that this does not reoccur, executive director and clinical director will meet semi-annually to ensure that the proper documents are available to comply with the exception. The semiannual meeting will take place on 6/15/2023 and mid June every year therafter. |