INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 10, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Alternative Counseling Associates, Inc. was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this investigation.
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
The facility failed to ensure that staff met the qualifications prior to employment in the position.
Employee #1 was promoted to the position of director on 1/6/2020. Employee #1 does not have the program planning experience that is required for this position.
This information was shared with the facility staff in order to provide technical assistance.
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Plan of Correction
1. Employee # 1 submitted a letter of exception to Ddap on 01/13/2020.
2. If the exception is not approved then the contingency plan will be implemented. The person who previously held the position of director, who does meet the Ddap regulations and requirements, will assume the role of Director immediately upon notification from Ddap. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
The facility failed to keep the exterior of the building free from hazards.
During the physical plant inspection, it was observed that the side walk on the west side of the 438 East main street building was cracked and damaged in several places which created a trip hazard. Additionally, a portion of the eaves, above the fire escape from the second floor, was rotted and had rusted nails protruding from it.
This information was shared with the facility staff in order to address the condition.
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Plan of Correction
1. Maintenance staff will patch sidewalk temporarily until weather is conducive to a permanent repair. This will be done by 02/02/2020
2. Within 90 days , maintenance staff will remove damaged areas of sidewalk , build frame, lay stone, and pour concrete. This will be completed by 04/21/2020
3. Director will monitor repair insuring compliance with Ddap regulations This will be completed by 04/22/2020
4. Maintenance staff will remove "rotted wood " and "rusted nails " This will be completed by 02/03/2020
5. Maintenance staff will replace eave with new board and nails. This will be completed by 02/03/2020
6. Director will monitor eave repair for compliance with Ddap regulations. This will be completed by 02/04/2020
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The facility failed to keep exits unobstructed at all times.
During the physical plant inspection, it was observed that the basement exit door in the 440 East Main St. building was locked with a keyed deadbolt. This exit serves as the second means of egrees from the basement level of the building.
This information was shared with the facility staff in order to address the condition.
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Plan of Correction
1. Maintenance staff will conduct weekly inspections to ensure that all stairways, hallways, and exits from rooms remain unobstructed. This will be completed by 01/22/2020
2.The exit door in the basement of ACA 440 E. High street building, will remain unlocked and open at all times. This will be completed by 01/22/2020
3. Director will monitor this issue for compliance with Ddap regulations. This will be completed by 01/22/2020 |