INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Child Guidance Resource Centers 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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705.28 (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 April, 2023 through January, 2024 fire drill logs during the inspection, the facility failed to document the amount of time it took for evacuation at the time of the drill. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facilities Manager will review the forms monthly and verify that all fields including amount of time it took to evacuate at the time of the drill are recorded. If in any instance evacuation information is incomplete, the drill will be redone. All drills will be reviewed monthly at the Environment of Care Committee. This committee will report on the status of compliance with drill requirements and other fire safety standards to the Operations group on a monthly basis. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative documents and an interview with the facility director, the project failed to document that the project director prepared, annually updated and signed a written manual delineating project policies and procedures.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Each December, the Project director will prepare, update and sign a written manual delineating project policies and procedures have been reviewed and updated as needed. This will be completed at the Child Guidance clinical meeting with the project director, the chief clinical officer and VP for quality taking part. Once this is completed, a document will be signed by the project director stated this process was completed. This document will be available for audits. Project director will ensure this is an agenda item each year. |