INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 14, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Council of Southeast Pennsylvania, 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:
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project and facility directors during the facility's July 2020 through June 2021 training year in one of two applicable personnel records reviewed.
Employee #2 was hired as the facility director on November 16, 2017. The personnel record documented 7 hours of annual training for the reviewed training year.
This is a repeat citation from the April 5, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Facility Director will be responsible for maintaining a record of training certificates for all project staff will be scanned and the hard copy will be placed in a marked binder to ensure that copies of certificates are present at all times. |
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 physical plant inspection, the facility failed to ensure that the two fire extinguishers, located in the main hallway and by the bathroom, were inspected and approved annually by the local fire department or fire extinguisher company. The date of the last inspection, as indicated on the tags, on both extinguishers was October 2020.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The project has communicated with the site owner regarding inspection of fire extinguishers. Fire extinguishers have since been inspected. The Facility Director will be responsible for ensuring compliance. An annual calendar reminder has been scheduled by the Facility Director and the Director of Administration and Operations to ensure inspections are completed annually when due. |