INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 3, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Central Montgomery MH/MR Center 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form completed on September 3, 2013, the facility failed to ensure that staff persons and volunteers received at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff in one of one personnel record reviewed.
The findings include:
On September 3, 2013, one personnel record and the SRFSR form were reviewed to verify that employees had STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff. The facility failed to ensure that staff persons received at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff in one of one personnel record reviewed, specifically, personnel record # 4.
Employee # 4 is an Intake/Discharge Coordinator and was hired June 2, 1997. Employee # 4 was due to complete at least 4 hours of TB/STD training by June 2, 1998. Employee # 4 completed TB/STD trainings on 7/24/1997 and 7/31/1997 but only received 2 hours of TB/STD training for both of the trainings combined. Also, employee # 4 completed TB/STD training again on December 4, 2000. However, employee # 4 only received 3 hours for the training and the 3 hours of training was combined with a HIV/AIDS training.
The findings were confirmed during an interview with the facility director on September 4, 2013 at approximately 3:00 P.M.
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Plan of Correction
Employee #4 will attend the DDAP sponsored TB/STD/Hepatitis training on 10/23/13. The Facility Director will keep track of all new staff to ensure that they are completing the mandatory trainings within the specified time frames set by the Department. Documentation of the training will be kept in the CORE Program Training File as well as the employee's personnel file. |
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 review of administrative documentation, the facility 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 at the end of the fiscal year.
The findings include:
The administrative documentation was reviewed on September 3, 2013. The facility was required 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 at the end of their fiscal year. The facility's 2011 through 2012 fiscal year ended on June 30, 2012. However, the facility's financial audit for this period was not completed until January 21, 2013.
The findings were confirmed during an interview with the facility director on September 3, 2013 at approximately 11:00 A.M.
This is a repeat citation. The facility was cited on September 21, 2012 for noncompliance with this standard.
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Plan of Correction
The Chief Financial Officer will inform the independent public accountant of the timeframe set by the Department in Regulation 709.25 by 9/30/13. The Chief Financial Officer will monitor the auditing process to ensure the audit will be completed in a timely manner. |