INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cen Clear Child 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 and a plan of correction is due on April 30, 2009.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the agency policy manual and the self reporting documented on the Division staffing forms submitted, the facility failed to document a policy which identified timeframes for the agency training protocol.
The findings include:
During the onsite licensing inspection conducted on April 8 , 2009, the agency policy manual was reviewed . The self report forms provided by the Division and completed by the Director were also reviewed. The agency policy did not document time frames for the completion of each of the components of the program as required. Furthermore, the agency self report form indicated that the agency training year was May To May for 2008-2009. Agency policy documented that the agency training year is to be tracked from August 1 to July 31 each year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the physical plant inspection held during the onsite licensing inspection of April 8, 2009, the facility failed to document that fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
Fire extinguisher inspection documentation was reviewed during the physical plant inspection on April 8, 2009. Documentation of the inspection tags on the fire extinguishers indicated that the previous year's inspection had expired in March 2009.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |