INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 17, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Livengrin Counseling Center 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 and a plan of correction is due on April 20, 2010.
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Plan of Correction
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709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documentation and conversation with the Quality Management staff it was determined that the project failed to develop goals and objectives for the fiscal year of July 1, 2009 to June 30, 2010.
The findings were:
A review of administrative documents on March 8 through March 9, 2010 indicated that the annual goals and objectives for the fiscal year of July 1, 2009 to June 30, 2010 were missing.
A conversation with the Quality Management Staff on March 8, 2010 confirmed that the annual goals and objectives for the fiscal year of July 1, 2009 to June 30, 2010 had not been developed.
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Plan of Correction
The President/CEO will develop goals and objectives for the fiscal year 7/1/09 to 6/30/10. The President of the Board of Directors will be responsible to ensure that the corrective action is implemented. Compliance will be monitored by the Director, TQM. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on March 17, 2010. The log was reviewed from January 2009 to February 2010. The facility failed to indicate whether an alternate exit route was used during the fire drill during the following months of 2009: February, March, April, May, June, July, August, September, October, November, December. Additionally, the facility failed to indicate whether an alternate exit route was used during the fire drill in 2010: January and February.
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Plan of Correction
The program manager will ensure that as of the fire drill on 4/27/10, all fire drill logs will contain documentation of the use of an alternate route. Compliance will be monitored by the director of outpatient services. Oversight will be provided by the Director, TQM. |