INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on May 22, and 23, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Gaudenzia (Common Ground) 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of employee training records on May 8, 2012, the facility failed to assure that each employee received a written individual training plan in one of eight personnel reviewed.
The findings include:
A review of eight employee records during the on-site inspection on May 22 and 23, 2012 revealed that employee #1 did not have a documented individual training plan for 2012. The last documented individual training plan was May 3, 2011.
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Plan of Correction
A training plan was completed for the corporate employee identified as deficient and dated in May 2012.
The Director of Training and the Director of Human Resources will ensure that all corporate staff complete an annual training plan as per organization policy in January of each year and monitor ongoing conformance.
The Program Director will ensure that a training plan will be completed in January of each year per policy for each employee at the facility and monitor ongoing conformance.
Target Resolution Date: Resolved
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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 a review of the audit provided by the facility, the project failed to complete the annual audit by the end of the project's fiscal year.
The findings include:
A review of the annual audit information was reviewed on May 8, 2012. The documentation provided during the review indication the report was completed and signed by the Board of Directors on February 20, 2012. The time frame to have the annual audit is at the end of the fiscal year. The fiscal year ends June 30, 2012. A facility has 6 months to complete and sign the annual audit. The annual audit was due by December 31, 2011.
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Plan of Correction
The Director of Finance will review the process for acquisition of an annual audit and collaborate with the external auditors to ensure that the organization's annual fiscal audit report is completed, reviewed, and signed within 6 months of the fiscal year end and monitor for ongoing conformance.
The Director of Finance assumes responsibility for obtaining the 2011/2012 audit and having it presented to the Board for signature by December 31, 2012.
Targeted date: 12/31/12 |