INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24 - 25, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Polaris Renewal Services, 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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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 the Staffing Requirements Facility Summary Report and ten personnel records during the annual inspection conducted on May 24 - 25, 2016, three employees were required to have documentation of HIV/AIDS and TB/STD training. Employee # 1 did not have documentation of HIV/AIDS and TB/STD training.
Employee # 1 has been in the position of project director since July 13, 2012.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Governing Body of Polaris Renewal Services will identify, in writing, to DDAP that the current Facility Director will be appointed as the Project Director of Polaris Renewal Services, effective June 15, 2016. The Facility Director is responsible for maintaining personnel and training files and ensuring that all staff receive both the required type and number of annual training hours. The current Project Director (Employee #1 ) has identified that he will not participate in Personnel or Training requirements. Since the current Facility Director has a personnel file and is willing to participate in any a nd all required trainings, the appointment of the Facility Director as the Project Director will allow for the overall management of the project and staff for the facility. The current Facility Director's qualifications and experience have already been approved by the Department. T |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facilty Summary Report and ten personnel records during the annual inspection conducted on May 24 - 25, 2016, the facility failed to provide documentation of at least 12 clock hours of training for the January - December, 2015 training year for the project director. No training hours were documented for employee # 1.
Employee # 1 has been in the position of project director since July 13, 2012.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Governing Body of Polaris Renewal Services will identify, in writing, to DDAP that the current Facility Director will be appointed as the Project Director of Polaris Renewal Services, effective June 15, 2016. The Facility Director is responsible for maintaining personnel and training files and ensuring that all staff receive both the required type and number of annual training hours. The current Project Director (Employee #1 ) has identified that he will not participate in Personnel or Training requirements. Since the current Facility Director has a personnel file and is willing to participate in any a nd all required trainings, the appointment of the Facility Director as the Project Director will allow for the overall management of the project and staff for the facility and will ensure that the 12 clock hours will be completed annually. The current Facility Director's qualifications and experience have already been approved by the Department. |
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
The facility's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services during the annual inspection conducted on May 24 - 25, 2016. The facility failed to provide documentation of an independent financial audit for the fiscal year ended December 31, 2014.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director for Polaris Renewal Services will submit in writing a request for exception for 28 PA Code 709.25(a) Financial Audit Requirement, as per the Licensing Alert issued in February 2011. Polaris did not have an independent audit completed for 2014 because the gross revenue did not exceed $500,000. However, the Facility failed to file an exception. The Project Director will file an exception for the 2015 Fiscal Year, as the gross revenue will still not exceed $500,000. If the exception is not approved by DDAP, Polaris Renewal Services will participate in an independent fiscal audit. The Project Director is responsible for the completion of the audit if needed. Based on 2016 revenue projections, Polaris Renewal does intend to complete a fiscal audit for the year 2016. |