INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the February 7, 2014 and February 10, 2014 licensure renewal inspection. The follow-up inspection was conducted on August 22, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, ADAPPT House 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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705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
Based on a review of the physical plant, the facility failed to ensure that the water temperature did not exceed 120 degrees.
The findings included:
During the physical plant tour on August 22, 2014, at 2:30 p.m., the hot water temperature at the sink in the women's bathroom by Exit F was checked. The hot water temperature was recorded at 127.8 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance personnel has purchased a digital thermometer which shall be used on a daily basis to ensure the hot water temperature does not exceed 120 degrees.
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a review of the physical plant, the facility failed to ensure that all fire extinguishers were inspected annually.
The findings included:
During the physical plant tour on August 22, 2014, at 2:30 p.m., the garage food storage area was inspected. The fire extinguisher located in the garage food storage area had not been inspected since April 2012.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire extinguisher in the garage food storage area has been replaced with a currently inspected fire extinguisher.
Going forward, maintenance or the fire inspection company shall ensure that all fire extinguishers are inspected annually. ADAPPT has a verbal agreement with Mogel Fire Protection, LLC to inspect all fire extinguishers on an annual basis. Maintenance shall ensure these annual inspcetions occur. The date of the inspection shall be indicated on the extinguisher or inspection tag.
Maintenance personnel shall inspect and also ensure all fire extinguishers are checked monthly.
Any inoperable fire extinguishers shall be removed within 48 hours of the time it was found to be inoperbsle |
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 documentation, the project 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.
The findings included:
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 on August 22, 2014. The facility's fiscal year runs from January 1 to December 31.
The facility did not complete an independent financial audit for the 2013 fiscal year. Additionally, the facility failed to produce documentation that an independent financial audit was conducted for the 2012 fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall be responsible for meeting with corporate counsel to ensure that the annual audit of financial activities for the January 2013 through December 2013, and January 2012 through December 2012 fiscal year is completed by November 1,2014.
The Project Director shall follow up annually to ensure that the audit of financial activities is completed and available by June 30th of each year. The Project Director shall maintain regular communication and monitor progress of a completed audit with corporate representatives at the beginning of each calendar year and request a completed annual audit of financial activities for the project so it is available by June 30th. |