INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 12, 2011 and October 13, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mid-Atlantic Rehabilitation Services - A.T. P. 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 the survey.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of staff development records, the facility failed to document HIV/AIDS and TB/STD training in one of two records reviewed.
Findings:
Eight staff development records were reviewed on October 12, 2011. Two of the eight staff development records were reviewed for documentation of HIV/AIDS and TB/STD training. The staff development record failed to include documentation of HIV/AIDS and TB/STD training in staff development record # 1.
Employee # 1 is a counselor who was hired on September 12, 2009. Documentation of the required training was not available at the time of the review on October 12, 2011
The facility director was interviewed on October 13, 2011 at approximately 13:30 and confirmed the finding.
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Plan of Correction
Clinician who was missing documented HIV/AIDS and TB/STD training will register as soon as possible for the above trainings and provide documentation for the personell file to the Director by 3/1/2012. Director will audit personell files to ensure compliance with training requirements by 1/31/2012. |
709.22(e)(2) 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:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the 2010 annual report the governing body failed to include a financial statement of income and expenses.
Findings:
The 2010 annual report was reviewed on October 12, 2011 The facility is publicly funded and required by regulation to make available to the public an annual report which includes a financial statement of income and expenses. On October 12, 2011 at 14:00 the annual report for the 2009/2010 was reviewed and found no to include a financial statement of income and expenses.
On October 13, 201 at approximately 13:45 PM the facility director was interviewed. The facility director confirmed that a financial statement of income and expenses had not been included in the annual report.
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Plan of Correction
Although a financial statement was not included in the annual report the facilities financial audit was available for review. Beginning with the annual report covering fiscal year 2011 (submitted to the agencies board in January 2012). The project director will include a page within the annual report that includes a financial statement of income and expenses for the prior fiscal year. |