INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 29, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Center for Families 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the facility's policy and procedures manual the project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of an assessment of staff training needs, an overall plan for addressing these needs, a mechanism to collect feedback on completed training, and an annual evaluation of the overall training plan.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Director added a review in front of training binder with review of who is responsible for tracking completed training and indicated what the timeframe and method for collecting feedback was. Policy will include that Director will review monthly assigned training and develop a plan. Correction is to note the process happening on site currently in writing. This is completed to reflect the procedure should director need delegation or have replacement. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection on May 29, 2025, the facility failed to ensure that exits from the nonresidential facility were unobstructed. An emergency exit door from the basement was obstructed, as it was locked.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director and head of facilities discussing door options so door can be maintained with an alarming system if breached in a non-emergency but remain accessibly used should a 2nd exit be needed and will ensure that it not not reoccur. Director will oversee completion. This will be completed by 6/30/25. |
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 2024 through May 2025 fire drill logs, the facility failed to document the exit route used on each drill. The information was missing from the following fire drill logs:
May 12, 2025
May 5, 2025
April 14, 2025
April 9, 2025
March 21, 2025
March 20, 2025
February 13, 2025
January 13, 2025
December 12, 2024
October 14, 2024
September 20, 2024
August 22, 2024
August 12, 2024
July 25, 2024
July 2, 2024
June 19, 2024
June 3, 2024
May 8, 2024
May 3, 2024
April 18, 2024
April 4, 2024
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director has removed the old antiquated form so staff only have the form with the correct info including Route. Director oversaw this action. DIRECTOR will ensure that the new form is used. |
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 review of the April 2024 through May 2025 fire drill logs, the facility failed to ensure that a fire alarm or smoke detector was set off during each fire drill. There was no documentation that a fire alarm or a smoke detector was set off during the following fire drills:
March 20, 2025
February 13, 2025
January 13, 2025
July 25, 2024
June 19, 2024
May 8, 2024
April 18, 2024
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director requested exemption from state to utilize a horn on site to simulate the alarm. Director overseeing the completion of this. If State does not grant exception Director will work with fire dept to utilize alarm for practice purposes. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the following unusual incidents: Theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director requested compliance develop bugler policy to add to the theft policy to indicate what staff should do in event site has a break in. Director will oversee this completion. |