INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 3, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Counseling and Adoption 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:
|
Plan of Correction
|
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills once a month.
No fire drill was conducted during the month of June 2024.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Effective immediately, the Director of Operations has been informed to conduct fire drills mid-month rather than the end of the month to allow for rescheduling if necessary due to unplanned issues. In addition, the CEO will monitor monthly reports to ensure fire drills are implemented and completed. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document case consultations in one of three applicable records.
The facility's policy and procedure manual states a case consultation must occur every 90 days.
Client #7 admitted October 29, 2024 and still a current client. There were no case consultations documented in client record.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Effective immediately, the Direcor of Counseling has implemented a three step approach to ensure case consultaitons are completed within the 90 day requirement.
1. Reminder emails are sent related to all cases coming up for review.
2. Review of all cases coming up for review are discussed by the Direcor of Counseling in weekly supervision meetings.
3. The Direcor of Counseling has established a form that is used to note completion of required case consutaitons. |