INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on February 13, 2012 through February 15, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Drug and Alcohol Treatment Services 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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709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the staffing requirements facility summary report the facility failed to notify the Department of a change in authorized maximum capacity.
The findings include:
The staffing requirements facility summary report was reviewed on February 13, 2012. The summary report, signed by the Project/Facility Director, indicated the facility had 464 clients. The facility is licensed by the Division for a maximum client capacity of 450.
The Facility Director acknowledged the facility was currently over the authorized client capacity of 450.
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Plan of Correction
The Executive Director composed a letter requesting an increase in the Agency client capacity from 450 to 550. The letter was mailed to Cheryl Williams the Director of the Division of Drug & Alcohol Program Licensure on 2/24/12.The Lackawanna County SCA was copied on the request. |