INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 8, 2011 through August 9, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Place 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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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 an interview with the Project Director and a letter from the Controller, the project failed to document the completion of an annual audit of financial activities by the end of the the project's fiscal year.
The findings include:
The Project Director was interviewed on August 5, 2011 and confirmed that an annual audit of financial activities has not been completed since June 24, 2010, which was for the fiscal year July 1, 2008 through June 30, 2009. The inspector was also presented with a letter from the Controller of Firetree, Ltd that indicated the 2010 audit was late and had not yet been completed as of August 8, 2011.
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Plan of Correction
Project Director will review DOH standard 709.25(a)relating to the completion of an independent annual audit with th e governing body of Firetree, Ltd. on 8/29/2011 to ensure their understanding.
Project Director will secure the 2010 annual audit from the governing body by 9/30/2011.
Governing body will secure completion of subsequent annual audits within six months following the end of the project's fiscal year to ensure ongoing compliance. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen from outside the counseling room.
The findings include:
A physical plant inspection was conducted on August 9, 2011 from 10:15 am - 11:20 am. Two counselor's offices at the end of the women's inpatient wing had doors with uncovered windows which could be seen from the outside. The facility director was present during the inspection. At 10: 48 am he confirmed the windows on the office doors allowed for sessions to be seen from the outside.
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Plan of Correction
Facility Director reviewed DOH standard 705.4 (3) related to ensuring privacy so that counseling sessions cannot be seen or heard outside the counseling room. counseling room walls shall extend from the floor to the ceiling.
Facility Director reviewed the above standard and findings that that two counselor's offices had windows in the doors that were uncovered with Maintenance Supervisor on 8/18/11.
Maintenance Supervisor installed window coverings on 8/23/11 to address this finding. Maintenance Supervisor will continue to maintain this and all physical plant standards. |