INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on March 5-6, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, RHJ Medical Center, Inc / Vandergrift, LLC 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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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 the 2011 annual report and administrative documentation, the facility failed to make the 2011 annual report available to the public.
The findings include:
The annual report for the 2011 year was reviewed on March 5, 2012. The facility is publicly funded and the governing body shall make the annual report available to the public. The 2011 annual report was not made available to the public.
Multiple interviews took place with the project/facility director throughout the licensing inspection. There was no documentation available for review which showed that the 2011 annual report was made available to the public.
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Plan of Correction
project/facility director will be responsible to ensure that the annual report for 2011(and annually thereafter)is made availible to the public by advertising in the local paper that the report will be availiblae at the faciltiy on a given day between 12-1pm. |