INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on (enter date) by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Men and Women For Human Excellence 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) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of twelve months of the facility fire drill log , the facility failed to provide documentation of a fire drill being conducted in the month of December 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director and/or supervisor will review the fire drill schedule dates with the staff assign to conduct the monthly fire drill (1) week prior to the actual fire drill dates.
After each fire drill the project director and/or supervisor will review the fire drill logbook to ensure that the documentation is completed in its entirely. This review of the fire drill schedule dates and documentation will ensure that each month staff conduct a fire drills, complete the required documentation, and log all fire drills documentation in the book. This will provide evidence that fire drills are being conducted each month by MWFHE.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of twelve months of the facility fire drill log, the facility failed to provide documentation of the exit route used in November 2019, if the alarm was operable in October 2019, and the number of persons present during the fire drill in June 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director and/or supervisor will ensure that all staff conducting a monthly fire drill will complete the fire drill documentation report in its entirely including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. After each fire drill the project director and/or supervisor will review the written fire drill documentation report to ensure each item (questions) on the report are completed in its entirely. This will provide evidence that MWFHE maintains accurate written fire drill record. |
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 of the financial audit provided by the facility, an annual financial audit was not completed for the year 2018- 2019. The last audit performed was conducted in December 2016.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from an inspection conducted in July 2019.
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Plan of Correction
MWFHE will correct the deficiency by completing the 2017-2018 financial audit within 90 days timeframe no later than July 30, 2020. The Financial Auditor , Cheryl Miller, CPA Associate , left a phone message for the CEO stating once the payment is secure she will have MWFHE 2017-2018 financial audit completed by July 30, 2020. The CEO personally certify that the payment for the financial audit will be sent today. As we move forward and in order to maintain compliance the CEO will be the responsible person to ensure that MWFHE financial audits be completed annually as required. During the annual budget meeting the CEO will also discuss with members of the Board the important of allocation, and compensation for all upcoming MWFHE financial audits so that we will maintain all funders' compliance. If needed MWFHE can request a letter from the Financial Auditor, Cheryl Miller, CPA Associate agency in order to confirm the 2017-2018 financial audit will be completed by July 30, 2020.
CEO personnaly ensures that upon completion of 2017-2018 financial audit on July 30, 2020 .. the Financial Auditor, Cheryl Miller, CPA Associate will begin working on MWFHE 2018-2019 Financial Audit.. Cheryl Miller, CPA Associate stated that she should be completed by October 31, 2020. Once the Auditior firm complete the 2018-2019 audit the Director of Programs will forward to DDAP. |