INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, T.W. Ponessa and Associates 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 on a review of staff CPR and first aid certifications, the facility failed to have a sufficient number of staff trained in these skills on-site between January 2022 and the time of the inspection during all hours of weekly operation.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director met with Director of support staff to discuss CPR/First Aide coverage requirement. All support staff will be required to be CPR/First Aide certified by 8/31/2022 as well for all new support staff. Support staff employees are always present during all open office hours which will ensure sufficient coverage. Clinical Director and Clinical Supervisor have obtained their CPR certification. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
A review of the January 2021 through June 2022 fire drill logs was conducted during the onsite inspection. The facility failed to include whether the fire alarm was operative at the time of the drill during the 2021 months of January, February, March, April, May, June, July, August, September, October, November, and December.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director met with the Property Maintenance Director to discuss the requirement to indicate whether the fire alarm was operable during the fire drills. Clinical Director added a column on the Fire Drill Log on 6/15/2022 asking for a Yes/No response for whether the alarm was operable at the time of each Fire Drill. |