INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 2008 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 and a plan of correction is due on August 29, 2008.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a July 29, 2008 review of facility records, the facility failed to complete the Staffing Requirements Facility Summary Report.
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Plan of Correction
The project director shall send a completed copy of the Staffing Requirements Summary Report to BDAP within 30 days of the inspection or earlier. |
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 July 29, 2008 review of employee records, the facility failed to ensure that one of one employees was currently certified in CPR.
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Plan of Correction
The Project Director shall send an updated copy of his CPR certification to BDAP within 30 Days of the date of the inspection. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a July 29, 2008 review of facility records the outpatient client to counselor caseload ratio could not be computed as the facility failed to complete the Staffing Requirements Facility Summary Report.
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Plan of Correction
The Project Director shall send a copy of the Staffing Requirements Facility Summary Report with the required counselor to client caseload information within 30 days of the date of inspection. |
705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
Based on a July 29, 2008 review of facility records, the facility failed to document written procedures for staff and clients to follow in case of an emergency, specifically the evacuation and transfer of clients and staff to a safe location.
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Plan of Correction
The Project Director shall write a revised set of procedures that will be followed by the staff and the clients in the case of an emergency. This shall include an identified method of egress from the building and a meeting place where the staff and clients can meet safely away from the building/emergency. He shall place a copy of the revision within the facility's Policy and Procedure Maual. |
705.27 (4) (ii) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(ii) Assignments of staff during emergencies.
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Observations
Based on a July 29, 2008 review of facility records, the facility failed to document written procedures for staff and clients to follow in case of an emergency, specifically assignments of staff during emergencies.
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Plan of Correction
The Project Director shall write a revision of the appropriate assignments for staff members in case of an emergency, and place a copy of the revised staff assignments document in the facility's Policy and Procedures Manual. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a July 29, 2008 physical plant inspection, the facility failed to ensure that two of two fire extinguishers were annually inspected and approved by the fire extinguisher company. The expiration date for inspections was June 2007.
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Plan of Correction
The Project Director has made a request to the building's owner to have the fire safety equipment recertified for compliance and shall check for this compliance within 30 days. |
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 July 29, 2008 review of facility records, the facility failed to conduct monthly unannounced fire drills from July 2007 to June 2008.
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Plan of Correction
The Project Director shall address this issue by writing a policy page specifically stating that fire drills must be conducted on a monthly basis. A copy of this will be placed in the facility's Policy and Procedsure Manual. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a July 29, 2008 review of facility records, the facility failed to conduct fire drills during normal staffing conditions from July 2007 to June 2006.
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Plan of Correction
The Project Director shall include in the Fire Drill Policy Page that fire drills shall be conducted during normal staffing conditions. |
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 July 29, 2008 review of facility records the facility failed to 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 from July 2007 to June 2008.
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Plan of Correction
The Project Director shall create and maintain a log of fire drills that includes the date, time, amount of time to evacuate the building, the number of people that were present in the facility, the route used for evacuation, and a note as to the functionality of the fire alarm or smoke detector at the time of the fire drill. This log shall be kept in the Facilty's Policy and Procedure Manual. |
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 July 29, 2008 review of facility records, the facility failed to prepare alternate exit routes to be used during fire drills from July 2007 to June 2008.
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Plan of Correction
A rendering of alternative evacuation routes shall be made and displayed in plain view in the facilty. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a July 29, 2008 review of facility records, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts from July 2007 to June 2008.
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Plan of Correction
A statement shall be entered in the fire drill policy page that shall include the information that fire drills shall be held on different days of the week at different times of the day. Being there is only one staff member he will have to be present at all fire drills. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a July 29, 2008 review of facility records, the facility failed to set off a fire alarm or smoke detector during each fire drill from July 2007 to June 2008.
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Plan of Correction
A statement shall be included in the fire drill policy page that specifies that a fire alarm or smoke detector shall be set off during each fire drill to test it's functionality. |
709.23(b)(3) 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:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a July 29, 2008 review of facility records, the facility failed to complete a report summarizing the progress towards meeting goals and objectives from the previous year.
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Plan of Correction
Within 60 days the Project Director shall prepare a report summarizing the progress made toward stated goals and objectives from the previous year. A copy of this report shall be placed in the facility's Policy and Procedure manual. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
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Observations
Based on a July 29, 2008 review of facility records, the facility failed to obtain any current letters of agreement with primary referral sources.
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Plan of Correction
Within 90 days the Project Director shall request letters of agreement with primary referral sources. These letters shall be kept on file at the facility. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a July 29, 2008 review of client records, the facility failed to document family medical histories in three of three client records reviewed, specifically client records # 1, 2 and 3.
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Plan of Correction
A revision shall be placed in the Policy and Procedure manual to state that family medical histories should be included in each client's file when and where possible. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a July 29, 2008 review of client records, the facility failed to thoroughly document personal histories. Personal histories were missing in three of three client records reviewed, specifically # 1, 2 and 3.
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Plan of Correction
The Project Director shall insert a notation in the Policy and Procedure Manual that more specific personal histories shall be taken and notated in each client's file. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on a July 29, 2008 review of three client records, the facility failed to thoroughly document medication records. Documentation in three of three client records reviewed was missing the dosage and frequency of use of the identified medications. The missing documentation was in client records # 1, 2 and 3.
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Plan of Correction
The Project Director shall prepare a notation to be placed in the Policy and Proceure Manual stating that all medications that are being taken by the client shall be noted as to the medicatioon, dosage and frequency of administration and recorded in the client's file. |