INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Milestone Rehabilitation, 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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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs and an interview with the project director, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on May 15, 2014. The time period reviewed was May 2013 through April 2014. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been set off from May 2013 through May 2014.
When interviewed, the project director advised that they had a print out from the alarm company verifying the alarm is functional, however it is not set off during the drills. The facility does not have an exception to not sound the fire alarm or smoke detector.
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Plan of Correction
The facility will ensure that the fire alarm and smoke detectors are set off next time and every time going forward when the facility conducts fire drills and it is documented on the fire drill logs with the signatute of the the Project Director. It shall be the duty of the Project Director to set alarm and smoke detectors off and confirm it by signing in the drill log before the fire drill starts. It will assure there are no steps missed in fire drills testing. |
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 a review of administrative documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services on May 15, 2014. The facility ' s fiscal year runs from July 1 to June 30. The facility did not document an independent financial audit for the 2013 fiscal year.
An interview with project director confirmed the findings.
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Plan of Correction
The facility will be contracting with an independant accountant to audit financial activities on annual basis. It shall be a duty of the Financial manager to make sure the independant audit of financial records completed on annual basis no later than November of the following year. The independant audit of financial activities in 2013 fiscal year is scheduled to occur in October 2014. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based upon a physical plant inspection and an interview with the project director, the facility failed to have the fee schedule posted in a prominent place.
The findings include:
A physical plant tour was conducted on May 15, 2014. The fee schedule was not readily observable during the tour. The project director was asked where the fee schedule was posted and was advised that it was not posted.
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Plan of Correction
The fee schedule has been posted in the reception area of the facility as of 05/15/2014. It shall be a duty of the Office Manager to verify if the schedule is in fact in place on the board in the reception area on daily basis. |