INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 27, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. The counseling office, adjacent to the doctor's office, did not have window coverings, which allowed counseling sessions to be seen from the exterior of the building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/27/22 Director contacted facilities department who came to the site and put blinds in the window to ensure privacy for staff and clients.
Director/Coordinator will complete monthly routine walk through of the site to ensure privacy is maintained in all offices. |
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 facility's May 2021 through April 2022 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills. The facility utilized the front door exit route during every fire drill conducted during the reviewed period.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
On 6/15/22 Director spoke with staff who conducts fire drills and explained that drills must be conducted using alternate exit routes each time. Moving forward staff and clients will complete fire drills by using the alternate exits.
Coordinator/Director will add "front door" and "back door" to the fire drill log in order to prompt the use of alternating exits each month. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee in one of two personnel records.
Employee #1 was hired as the Project Director on March 4, 2019. The annual written staff performance evaluation dated May 2, 2022, was not signed by the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Human Resources will review the online performance evaluation system to ensure that evaluations cannot be finalized without signature.
As of 5/27/22 Project Director signed her performance evaluation.
Human Resources will monitor all submitted evaluations and will return any submitted without signature. This will ensure that evaluations are signed and then submitted. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the project's hours of operation to the general public.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As of 5/27/22, after the survey, the hours of operation were displayed on the door so as to be visible to the public.
Director/Coordinator will complete monthly routine walk through of the site to ensure the hours of operation, contact information, and emergency numbers remain posted. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display a telephone number for emergency purposes to the general public.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As of 5/27/22, after the survey, the telephone number and emergency phone numbers were displayed on the door so as to be visible to the public.
Director/Coordinator will complete monthly routine walk through of the site to ensure the hours of operation, contact information, and emergency numbers remain posted and visible to the public |