INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 4, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CJ Therapy Group LLC 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain hot water not exceeding 120 degrees. The bathroom's hot water was recorded at 136 degrees.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The hot water heater was reset to comply with the regulation of 120 degrees or less. This was completed the day of inspection. Project director will be responsible for monitoring this on a weekly basis to ensure the temperature does not exceed 120 degrees. |
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain a portable fire extinguisher located on each floor. There was no fire extinguisher in the basement.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Portable fire extinguisher was placed in the basement to comply with requirements. project director will be responsible for maintaining the fire extinguisher on each floor to maintain compliance. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #1 was hired on July 8, 2024 as the Project Director/Facility Director and was still in the position as of the date of the inspection. No training was completed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
fire extinguisher training plan has been implemented. training has been completed through OSHA virtually. This training will be monitored by the project director in each employee file to ensure it is completed within 7 days after hiring any new employee |
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.
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Observations
Based on a review of fire drill logs from June-December 2024 and January 2025, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of June through December, 2024.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
A fire drill log has been implemented and unannounced fire drills will be completed at least once a month led by project director to ensure compliance. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Employee #1 was hired on July 8, 2024 as the Project Director/Facility and was still in the position as of the date of the inspection. No training was completed.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Emergency action plan implemented, and employees assigned tasks during emergencies. Training and log of training has been implemented and will be monitored by project director in employee file to ensure this is completed within 7 days of hiring any new employee. |
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 the June 2024 through January 2025 fire drill logs during the inspection, the facility failed to document whether the fire alarm or smoke detector was operative in the facility at the time of the drill.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
A space on the fire drill log has been added to document whether the fire alarm or smoke detector is operative at the time of the drill. Project director responsible for correct documentation. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to complete a written individual staff performance evaluation according to the facility's policy and procedure. The facility's policy and procedure manual states that an evaluation will be completed at 90 days from date of hire and then annually thereafter.
Employee #1 was hired as the Project Director/Facility Director on July 8, 2024 and was still employed at the time of the inspection. An annual written performance evaluation was due no later than September 8, 2024. No evaluation has been completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
written individual staff performance evaluation has been created and implemented for each employee to be completed on an annual basis and has been correctly added to the policy and procedures manual. the project director will be responsible for the evaluation of all employees. |
709.42(f) LICENSURE Display of Phone #
709.42. Project management.
(f) A telephone number 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 telephone number to the general public for emergency purposes.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The telephone number for general public for emergency services and purposes is now displayed on the entrance door. The project director will be responsible for maintaining the visibility of this number to ensure it is legible once monthly. |