INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 3, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gentle Force Counseling Services, LLC 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 March 2021-October 2021 fire drill logs, the facility failed to include documentation of the exit route used and whether the fire alarm or smoke detector was operative on all logs. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will maintain a written fire drill record
The Facility Director will ensure that all fire drill documentation is completed monthly and will include a written record of 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.
The Clinical Director will review the agency's fire drill record binder on a regular basis to review and document that fire drills are conducted and documented accordingly. |
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 review of the March 2021-October 2021 fire drill logs, the facility failed to prepare alternate exit routes to be used during the fire drills. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will maintain a written fire drill record
The Facility Director will ensure that all fire drill documentation is completed monthly and will include a written record of 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.
The Clinical Director will review the agency's fire drill record binder on a regular basis to review and document that fire drills are conducted and documented accordingly. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
Based on a review of the policy and procedures manual, the facility failed to include a reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws in their policies and procedures. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will include a reporting mechanism to ensure that reporting of an unusual incident to an entity is reported, documented accurately, and is in compliance with State and Federal confidentiality laws.
The Project Director will update policies and procedures-unusual incident policy on reporting mechanism, by December 10, 2021. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the policies and procedures manual, the facility failed to include filing an unusual incident report with the department within three days involving physical assault or sexual assault by staff or a client. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will document that the facility will file an unusual incident report with the department within three days involving physical assault or sexual assault by staff or a client.
The Project Director will update the unusual incident policy on reporting unusual incidents to the department within three days, by December 10, 2021. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the policies and procedures manual, the facility failed to include filing an unusual incident report with the department within three days involving death or serious injury due to trauma, suicide, medication error or unusual circumstances. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will update the policies and procedures manual to include that the facility will file an unusual incident report with the department within three days involving death or serious injury due to trauma, suicide, medication error or unusual circumstances.
The Project Director will update the unusual incident policy on reporting unusual incidents to the department within three days, by December 10, 2021. |
709.34 (c) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
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Observations
Based on a review of the policies and procedures manual, the facility failed to include filing an unusual incident report with the department within three days involving significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence which closes the facility for more than 1 day. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will update the policies and procedures manual to include that the facility will file an unusual incident report with the department within three days involving significant disaster such as a fire, storm, flood or other occurrence which closes the facility for more than the one day.
The Project Director will update the unusual incident policy on reporting unusual incidents to the department within three days, by December 10, 2021. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the policies and procedures manual, the facility failed to include filing an unusual incident report with the department within three days involving event at the facility requiring the presence of police, fire or other ambulance personnel. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will update the policies and procedures manual to include that the facility will file an unusual incident report with the department within three days involving the facility requiring the presence of police, fire, or other ambulance personnel.
The Project Director will update the unusual incident policy on reporting unusual incidents to the department within three days, by December 10, 2021. |
709.34 (c) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a review of the policies and procedures manual, the facility failed to include filing an unusual incident report with the department within three days involving outbreak of a contagious disease requiring CDC notification. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will update the policies and procedures manual to include that the facility will file an unusual incident report with the department within three days involving outbreak of a contagious disease requiring CDC notification.
The Project Director will update the unusual incident policy on reporting unusual incidents to the department within three days, by December 10, 2021. |
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 a physical site inspection, the facility failed to display the hours of operation conspicuously to the general public. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will order facility sign for the outside of the building that will display the hours of operation conspicuously to the general public, by December 10, 2021. |
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 a physical site inspection, the facility failed to show a telephone number displayed conspicuously to the general public for emergency purposes.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will order facility sign for the outside of the building that will display a telephone number to the general public for emergency purposes, by December 10, 2021. |