INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northwester Human Services of Delaware County Inc. 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 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of a fire extinguisher upon staff employment, in two of four personnel records reviewed.
The findings include:
Four personnel records were reviewed on January 21, 2016, two of which were for newly hired staff and required documentation that fire extinguisher training had been provided in accordance with the standard. The facility failed to document the completion of fire extinguisher training upon employment in personnel records, #2 and 4.
Employee #2 was hired on May 26, 2015. The training was not documented as of the date of the inspection.
Employee #4 was hired on December 4, 2015. The training was not documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon hire all individuals will be enrolled in fire safety and fire extinguisher training. Staff will sign acknowledgement form that training was completed. Acknowledgement will be kept in personnel file. Additionally fire extinguisher training will be added to individual training tracking form for management tracking mechanism.
This will be implemented immediately for those cited. Ongoing for new hires.
Project director will be responsible for implementation and tracking. |
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 administrative paperwork and an interview with the Executive Director and Facility Director, the project failed to provide an independent annual audit of financial activities associated with the project's drug/alcohol abuse services by the end of the fiscal year.
The findings include:
The Licensing Specialist requested to see a copy of the project's annual financial audit during the licensing process. The financial audit was to be complete by the end of the fiscal year. The Project's fiscal year runs July 1 to June 30. However, a financial audit for the Project's fiscal year July 1, 2014 to June 30, 2015 was not presented for review as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We did not receive final reconciliation from county until 1-6-2016. Our understanding is this related to state budget. We requested multiple times during last 2 months of 2015. We could not complete our independent audit until this was received. Our audit has been completed and is available. This year we will again begin inquiring to county several months in advance of calendar year-end to assure audit will be complete by 12-31-2016. Fiscal department is responsible to contact county for reconciliation and to have audit completed by independent auditors by required date. |