INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 14 and 15, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Dreamlife Recovery LLC 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 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of the project fiscal management, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities for the fiscal year 2021, 2020, and 2019.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 29, 2021 and August 19, 2020 annual licensing inspections.
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Plan of Correction
The facility submitted an exception request for the financial audit on 10/10/2022.
If the exception is not approved, the project manager (Vice President of Operations) will ensure that the financial audits are available for presentation during the inspection required by the regulations. The project manager will work with the accountant and owners to ensure that Dreamlife Recovery is in compliance prior to the 2023 inspection with the financial audits from 2020 and 2021.
The 2020 financial audit will be completed by December 31, 2022 and the 2021 financial audit will be completed by June 30, 2023.
The 2019 financial audit has already been completed.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of the administrative information, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, was submitted and approved by the Department for the September 29, 2021, and August 19, 2020, annual licensing inspections. An annual financial audit was again found to be a deficiency in the September 14 - 15, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project manager (Vice President of Operations) will ensure that the plan of corrections are being followed by reviewing the progress on the plans monthly to ensure target goal dates are being met consistently. If the deadlines are not being met for the POC, the project manager (Vice President of Operations) will escalate the issue internally to the owners to ensure that resolve happens immediately.
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