INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Centre Counseling Associates 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 the sole proprietor's training documentation and the policy and procedure manual, the facility failed to document an individual training plan for the January 1, 2011 through December 31, 2011 training year.
The findings include:
The sole proprietor's training records, files and policy and procedure manual were reviewed during the licensing inspection conducted on September 29, 2011. There was no documentation of the individual training plan for the January 1, 2011 through December 31, 2011 individual training plan.
During an interview conducted with the Sole Proprietor at approximately 2:15 PM, the Sole Proprietor confirmed that he could not locate the individual training plan.
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Plan of Correction
The Project Director has developed a format for the individual training plan and it has been incorporated into the Policy and Procedure Manual. The individual training plan format will ensure that at least 25 hours of training are obtained annually. The training year will be established as November 1 through October 30 of each year. The individual training plan will include the subject of the anticipated training, the time frame within the year for obtaining the training and resources available for securing the training. An individual training plan for the training year November 1, 2011 through to October 30, 2012 will be documented and maintained on file as of November 30, 2011. The Project Director/Sole Proprietor will ensure ongoing compliance.
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
The letters of agreement were reviewed on September 29, 2011. The only letter of agreement regarding 24- hour emergency services was for emergency psychiatric services. The facility failed to obtain a written letter of agreement or understanding for 24 hour emergency medical services.
The project director was interviewed on September 29, 2011. It was confirmed at that time that no other documentation of a letter of agreement or understanding for 24- hour emergency medical coverage was available.
This is a repeat citation. The facility was found not to be in compliance during the inspections conducted on 3/29/11, 11/ 23/10 and 11/30/09.
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Plan of Correction
The Project Director will continue to work with Mount Nittany Medical Center to obtain a letter of understanding, which specifically excludes the possibility of fiduciary responsibilities for either party, but states that the Medical Center does provide for 24 hour emergency medical and psychiatric care. The letter will further state the clients of Centre Counseling Associates will have access to that emergency care just as any other resident would. The letter will be obtained by December 31, 2011. Several attempts over the last year have been made to obtain such a letter of understanding, but to date, the Medical Center has not responded. The Project Director will ensure that the letter of understanding is obtained by December 31, 2011. |
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 all administrative material provided during the inspection, ,the project failed to document the completion of an annual audit of financial activities for fiscal year 2010.
The findings include:
The sole proprietor was interviewed on September 29, 2011 at approximately 2:15 PM. The project director confirmed that an annual audit of financial activities had not been completed for the January 1, 2010 through December 31, 2010 fiscal year.
This is a repeat citation. The facility was found not to be in compliance during the inspections conducted on 3/29/11, 11/ 23/10 and 11/30/09.
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Plan of Correction
The Project Director has submitted an exception request for the standard that requires an annual audit. The facility is a sole proprietorship and has no staff. The facility does not receive public funds and has annual incomes that are consistently under $100,000.00 . Should the Department of Health not grant the exception, an annual audit for fiscal year 2010 will be prepared and made available by January 31, 2012. The extra time is required to raise funds to pay for the audit. The Sole Proprietor/Project Director will ensure ongoing compliance. |