INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, T.W. Ponessa and Associates Counseling 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:
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff CPR and first aid certifications, the facility failed to have a sufficient number of staff trained in these skills on-site between January 2022 and the time of the inspection during all hours of weekly operation. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director met with Director of Support staff to discuss the requirement of having sufficient number of staff trained in CPR/First Aid on-site for all open hours. All support staff will be trained in CPR/First aid by 8/1/2022 as they are present during all open office hours. Clinical Director obtained her CPR certification on 6/13/2022 and will obtain her First Aid Certification by July 31, 2022. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of July 2021-May 2022 fire drill logs, the facility failed to include documentation of whether the fire alarm was operative on all logs. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director met with Property Manager to discuss the requirement of documenting whether the fire alarm was operative on all logs. Clinical Director added "Fire Alarm/Smoke Detector Functional" section on the Fire Drill Log prompting to answer with a Yes/No for each monthly fire drill. |
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 July 2021-May 2022 fire drill logs, the facility failed to prepare alternate exit routes to be used during the fire drills. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director met with Property Manager to discuss the requirement of preparing alternate exit routes during fire drills. Property manager will alternate exit routes starting with July's fire drills. |