INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 17-18,2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mission New Life 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 September 15, 2010.
|
Plan of Correction
|
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.
|
Observations
Based on a review of administrative materials during the onsite inspection the facility failed to have an annual audit for the fiscal year 2008-2009 was not completed.
The findings include:
The Mission New Life Policy and Procedure Manual was reviewed on August 17, 2010 and an interview with the Facility Director and Executive Director at 10:30 AM confirmed an annual audit was not done.
This is a repeat citation.
|
Plan of Correction
A Board approved request for an exception to the regulation requiring an annual audit of financial activities associated with Mission New Life's drug/alcohol abuse services was mailed to the Department on September 3, 2010. At its regular meeting on September 17, 2010, Mission New Life's Board unanimously ratified its approval of the request. The request is based on the financial hardship such an audit would impose on Mission New Life's $115,000 a year budget. In lieu of an annual audit, the Board respectfully requests that Mission New Life be permitted to submit copies of its internal QuickBooks financial statements and Form 990 on an annual basis. |
709.29(a) & (b) LICENSURE Retention of Client Records
709.29. Retention of client records.
(a) Client records, whether original, reproductions or microfilm, shall be kept on file for a minimum of 4 years following the discharge of a client.
(b) If the project discontinues operation, it shall make known to the Department where its records are stored.
|
Observations
Based on a review of the policy and procedure manual and an interview with the Facility Director, the facility failed to have a policy in place if the project were to discontinue.
The findings include:
Based on an on-site inspection of the policy and procedure Manual on August 17, 2010 and an interview with the facility Director, the facility failed to have a policy in place as to where the client records would be stored if the project were to cease operations.
|
Plan of Correction
Mission New Life's Executive Director will submit for Board approval at its regular meeting on September 17, 2010, a policy regarding retention of client records for a minimum of 4 years following discharge of a client. The Executive Director will also submit to the Board, a policy regarding disposition and storage of client records as well as notification to the Department of where records would be stored should Mission New Life discontinue operations. |
704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
|
Observations
The project shall develop a written policy to address relapse of recovering clinical personnel.
The findings include:
A review of the project policy and procedure manual on August 17, 2010 and an interview with the facility director confirmed that the facility did not have a policy to address the relapse of recovering clinical personnel.
|
Plan of Correction
Mission New Life's Executive Director will submit for Board approval at its regular meeting on September 17, 2010, a policy addressing the relapse of recovering clinical personnel. |
704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document a policy that addressed the recruitment and hiring of staff persons who were appropriate to the population to be served.
The findings include:
An interview with the facility director and a review of the policy and procedure manual on August 17, 2010 at 10:30 AM, confirmed the facility failed to address a policy pertaining to the recruitment and hiring of staff persons who are appropriate to the population to be served.
|
Plan of Correction
Mission New Life's Executive Director will submit for Board approval at its regular meeting on September 17, 2010, a policy addressing the recruitment and hiring of staff persons who are appropriate to the population served by Mission New Life. |
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.
|
Observations
Based on the review of staff individual training plans, the facility failed to document the required information for individual training plans.
The findings include:
Five staff written training plans were reviewed on August 17, 2010. Five of the staff training plans failed to have the date when the plan was developed and the signature of the employee and supervisor in place.
|
Plan of Correction
As of August 15, 2010, Mission New Life's Executive Director has reviewed with each staff member their individual training plan for the Year 2010. Both the Executive Director and the staff member signed and dated the staff member's plan for the current training year. In December of this year, the Executive Director will review with each staff member their individual training plan for the Year 2011. The Executive Director and each staff member will sign and date the staff members agreed upon individual training plan for the Year 2011. |