INITIAL COMMENTS
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This report is a result of an initial on-site licensing inspection conducted on January 15, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the initial inspection, Little Creek Lodge, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
Since this was the initial inspection conducted, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
The following deficiencies were identified.
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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 presurvey material, the facility failed to provide documentation that CPR certification and first aid training was provided to a sufficient number of staff persons so that at least one person trained in CPR and First Aid skills was onsite during the project's hours of operation.
The findings include:
Presurvey material was reviewed on January 15, 2015. The facility failed to provide documentation that Employee #1 and Employee #2 were trained in CPR and First Aid skills in order to ensure that at lease one person trained in these skills was onsite during the project's hours of operation.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.23 (1) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(1) Maintain space for both individual and group counseling sessions.
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Observations
Based on observation during the physical plant inspection, the facility failed to maintain space for both individual and group counseling sessions.
The findings include:
A physical plant inspection was conducted on January 15, 2015. The facility failed to designated space for both individual and group counseling sessions. At the time of the inspection, the office space consisted of one large room.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.23 (2) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on observation during the physical plant inspection, the facility failed to maintain furnishings in good repair for individual and group counseling sessions.
The findings include:
A physical plant inspection was conducted on January 15, 2015. The facility failed to maintain furnishing in good repair for individual and group counseling sessions. At the time of the inspection, the office space consisted of one large room and the only furnishings were folding chairs.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation during the physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The findings include:
A physical plant inspection was conducted on January 15, 2015. The facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. At the time of the inspection, the office space consisted of one large room with no interior walls or window coverings.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.23 (4) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(4) Locate counseling areas so that noise does not disturb or interfere with counseling sessions.
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Observations
Based on observation during the physical plant inspection, the facility failed to locate counseling areas so that noise does not disturb or interfere with counseling sessions.
The findings include:
A physical plant inspection was conducted on January 15, 2015. The facility failed to to locate counseling areas so that noise does not disturb or interfere with counseling sessions. At the time of the inspection, the office space consisted of one large room.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on observation during the physical plant inspection, the facility failed to conspicuously display the hours of project operation to the general public.
The findings include:
A physical plant inspection was conducted on January 15, 2015. The facility failed to display the hours of project operation that can be accessed by the general public in case of an emergency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on observation during the physical plant inspection, the facility failed to conspicuously display a telephone number to the general public for emergency purposes.
The findings include:
A physical plant inspection was conducted on January 15, 2015. The facility did not display an emergency telephone number that can be accessed by the general public in case of an emergency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |