INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from September 26 - 27, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Spring-Ford Counseling Services, Inc., 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(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based upon the review of the facility's hours of operation, staffing schedules and documentation of CPR certification / first aid training, the facility failed to ensure that at least one person trained in these skills is onsite during the project's hours of operation.
The findings include:
The facility's hours of operation are Monday through Thursday, 9:00 AM to 5:00 PM and Fridays 9:00 AM to 1:00 PM. The facility also provides evening hours from Monday through Thursday, by appointment only.
The facility employs 3 staff members: a part-time Project / Facility Director (PD/FD), a part-time contract counselor, and a full-time Office Administrator. Staffing schedules for the time frame of August 30, 2012 to September 26, 2012, were reviewed on September 27, 2012. The facility was closed September 3, 2012, due to the Labor Day holiday.
Employee # 1, the PD/FD, was hired on July 1, 2000. Employee # 1 worked Monday through Friday, from 9:00 AM to 3:00 PM. As per the schedule, the only day that the PD/FD did not work was September 4, 2012. In addition, the PD/FD was on site until 5:00 PM on September 26, 2012.
Employee # 2, a contract counselor for the Drug and Alcohol project, was hired on November 3, 2011. Employee # 2 worked on the follow days and at the corresponding times.
September 5, 10, 12, and 17, 2012, from 5:30 PM to 8:30 PM
September 24, 2012, from 5:30 PM to 7:30 PM
Employee # 3, the Office Administrator, was hired on March 12, 2001. Employee # 3 worked Monday through Friday, from 9:00 AM to 5:00 PM.
CPR certifications and 1st Aid training for three employees were reviewed on September 27, 2012. The facility did not provide documentation of valid CPR certification and 1st Aid training for 2 of 3 employees, specifically #'s 2 and 3.
Employee # 1 had a CPR / 1st Aid card that was valid through June 4, 2013.
A valid CPR / 1st Aid card was not presented for employee # 2.
A valid CPR / 1st Aid card was not presented for employee # 3.
Based upon a comparison of the facility's staffing schedules and CPR / 1st Aid cards, the facility failed to ensure that at least one person trained in these skills was on site for the following dates and corresponding times:
August 30 and 31, 2012, from 3:00 PM to 5:00 PM
September 4, 2012, from 9:00 AM to 5:00 PM
September 5, 2012, from 3:00 PM to 5:00 PM and 5:30 PM to 8:30 PM
September 6 - 7, 2012, from 3:00 PM to 5:00 PM
September 10, 2012, from 3:00 PM to 5:00 PM and 5:30 PM to 8:30 PM
September 11, 2012, from 3:00 PM to 5:00 PM
September 12, 2012, from 3:00 PM to 5:00 PM and 5:30 PM to 8:30 PM
September 13 and 14, 2012, from 3:00 PM to 5:00 PM
September 17, 2012, from 3:00 PM to 5:00 PM and 5:30 PM to 8:30 PM
September 18 - 21, 2012, from 3:00 PM to 5:00 PM
September 24, 2012, from 3:00 PM to 5:00 PM and 5:30 PM to 7:30 PM
September 25, 2012, from 3:00 PM to 5:00 PM
The findings were originally reported by the Project / Facility Director.
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Plan of Correction
Within 90 days, both staff #2 and #3 will be trained in both CPR and First Aid, scheduling of CPR and First Aid will be monitored by Director. In the interim, employee hours will coincide with an employee that is certified, no sessions will be scheduled when the certified employee is not on site. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based upon the review of administrative documentation, the physical plant inspection, and an interview with the Project / Facility Director (PD/FD), the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
The project's 2011 / 2012 and 2012 / 2013 Goals and Objectives reviewed on September 26, 2012. The following documentation was included:
Goals & Objectives, FY '11/'12
Goal # 3, Improve Building Space
a. Work with building owner regarding roof leakage by June 30, 2012, implemented by
Executive Director
Goals & Objectives, FY '12/'13
Goal # 3, Improve Building Space
a. Continue to work with building owner regarding roof leakage by June 30, 2013,
implemented by Executive Director
The physical plant inspection was conducted on September 27, 2012, from approximately 8:50 AM to 9:15 AM.
Two ceiling tiles in the conference room, two ceiling tiles in the counselor's office next to the conference room, and two ceiling tiles in the visitor / client bathroom were stained. In addition, a section of the plywood sub-floor above the stained ceiling tiles in the conference room was stained.
An interview conducted with the PD/FD during the physical plant inspection revealed that the facility has been experiencing ongoing problems with a roof leak. In addition, the stained ceiling tiles have been replaced in the past but continue to be stained when there is a significant rainfall.
The findings were confirmed by the Facility Director during the physical plant inspection.
This is a repeat citation from the September 22, 2011, annual inspection.
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Plan of Correction
Director has repeatedly discussed roof leakage with Building Owner. Upon inspection, management again sent out repair workers to stop roof leakage. Ceiling Tiles have been replaced.
Agency Director will continue to monitor roof leakage and change out water damaged tiles on an as needed bases. If the roof leaks, ceiling tiles will be replaced and a certified water restoration company will inspect any new damage.
Executive Director will advise landlord to fix roof/leakage issue permanently by January 31, 2013 or Executive Director may need to investigate other space to rent. |
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 Administrative documentation, the facility failed to make a financial statement of income and expenses available to the public as part of the original annual report.
The findings include:
The project's Administrative documentation, which included the 2010 / 2011 Annual Report, was reviewed on September 26, 2012. The Annual Report included financial statements of income and expenses that were late as they were added on or after March 21, 2012. Therefore, the annual report did not include the financial statements when it was originally made available to the public.
The findings were confirmed by the Facility Director during the Administrative review.
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Plan of Correction
Director shall complete Annual Report with an audit report, if audit report is not completed by auditor by December 31, 2012, Director shall use income and expense report derived from accounting system to be included with Annual Report. |
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 upon the review of administrative documentation, the facility failed to provide, through written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
Administrative documentation, which included written referral agreements, was reviewed on September 26, 2012. The facility failed to obtain a written agreement that provided for 24-hour emergency medical coverage.
The findings were confirmed by the Project Director during the administrative review.
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Plan of Correction
Within 120 days, Director shall obtain a written referral agreement from an area licensed hospital or physician for 24-hour emergency medical coverage. Director shall keep this agreement updated per every two years. |
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 upon the review of Administrative documentation, the project failed to have an annual audit of financial activities associated with the project's drug/alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
Administrative documentation was reviewed on September 26, 2012.
The project's fiscal year runs from July 1 to June 30. The annual financial audit was late as it was completed on March 21, 2012.
The findings were confirmed by the Project Director during the review.
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Plan of Correction
By December 31, 2012 financial audit for 2011-2012 will be completed. Director to ensure timely completion of financial audit.
The auditors have already begun their audit for 2011-2012 fiscal year. Director has communicated the need for audit report to be completed in a timely fashion and by December 31, 2012. |