INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2007 through September 11, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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 and a plan of correction is due on October 4, 2007.
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Plan of Correction
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709.22(e)(1) 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:
(1) Activities and accomplishments of the preceding year.
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Observations
Based upon review of the 2005-2006 annual report during the corporate visit conducted August 8, 9, 10, 13 and 14, 2007, it was determined that the facility failed to identify activities and accomplishments of the preceding year for the program. The Findings were: The annual report did not include a statement for each individual program.
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Plan of Correction
The annual report for the FY 2007 will be printed and available to the public for the current FY and every year thereafter. It will include activities and accomplishments for the previous FY. The report will include a statemenr for each individual program. Person responsible will be the Director of Development. Time frame 8.31.07 |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based upon review of the goals and objectives for the 2007-2008 fiscal year it was determined that the facility failed to identify available resources and time frames for achievement. The Findings were: The majority of the goals and objectives do not include available resources and time frames for achievement.
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Plan of Correction
Executive Staff who are responsible for specific goals will develop and revise plans in specific goal areas in consultation with their respective Board Committees and available resources for approval at the September Board meeting and every September thereafter. Persons responsible are Executive staff. Time frame is 12/07. |