INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Centre Counseling Associates 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 facility staff CPR/first aid certification cards, the facility failed to ensure that at least one person trained in CPR skills onsite during the project's hours of operation.
Findings:
Based on a review of staff schedules and staff CPR/first aid certification cards, the facility did not have any staff trained in these skills on duty.
staff #1 is the sole owner and the Project/Facility Director and counselor. Staff #1 had a CPR/First Aid certification with a expiration date of June 2013.
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Plan of Correction
The Project director shall within the next 60 days renew his CPR certification and keep it at the agency for review. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of staff development records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel records reviewed.
The findings included:
One personnel record were reviewed on September 25, 2013. One personnel record was the project/Facility Director and the only counselor. Staff #1 was required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 1. Six training hours for this staff member were completed for the period between January 1 to December 31, 2013.
This was confirmed by the PD/FD/Counselor On September 25, 2013.
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Plan of Correction
The Project Director reviewed yhe examiners finding and found it to be accurate. The Project Director shall endeavor to review the next training year with the new understanding that the examiner reviewed with him as to when the trainings must be achieved in order to be in compliance with the requirements. The Project Director acknowleges his mistake and will ensure it will not occur again. |
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on a physical plant tour on September 25, 2014, the facility failed to provided a smoke detector within the facility.
The findings include:
Based on a physical plant tour with the director, the facility did not have a working smoke detectors. The Director confirmed the battery did not work on the only smoke detector in the facility suite.
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Plan of Correction
It is a normal part of the fire drill plan in place to check the fire detectors functionality and it had been checked but the battery had expired after the last check. The Project Director will check the battery function on the fire detector at least 3 times per month and make sure a spare battery is on site. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on the review of the agency policy and procedure manual and administrative reports on September 25, 2013 and an interview with the Project/Facility Director, the facility failed to document annual goals and objectives which include time frames for the current fiscal year.
The findings included:
The annual onsite licensing inspection was conducted September 25, 2013 at this facility. As part of the inspection, the agency policy and procedure manual and administrative reports were reviewed. No documentation was presented to support the fact that the Project Director and the governing body formulated annual goals and objectives for the fiscal year 2012 and 2013.
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Plan of Correction
The Project director shall formulate and record a set of new goals and objectives and place it within the Policy and Procedure maual within 60 days. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services on September 25, 2013.
The facility did not document an independent financial audit for the (year under review) fiscal year.
An interview with Project/Facility Director confirmed the findings.
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Plan of Correction
The Project Director has submitted a letter for exemption from having to have an audit done. The letter has been received by BDAP and is being reviewed. If the request for an exemption from audit should be refused the Project Director will arrange for an audit to be conducted within 60 days of the refusal. |