INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Centre Counseling Associates 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(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 the clinical staff records, the facility failed to ensure that at least one staff person was certified in CPR at the time of this inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Within 60 days the Project Director will take and document a CPR course to bring this issue into compliance. The Project Director has always kept this up to date but Covid intervened to cause this discrepancy. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of the fiscal management records, the facility failed to provide 2020 tax returns at the time of this inspection. The facility has been granted an exception that in lieu of obtaining the services of an accountant to conduct an annual financial audit, the facility would provide tax returns at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director shall make available his Federal Income Tax forms that are relevant to the facility. I file together with my wife an individual tax form. The forms will omit any documentation in relationship to any of my wife's personal tax information. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document short-and long-term goals on the treatment plan updates in one out of one client record reviewed.
Client #1 was admitted on December 15, 2010 and was still active at the time of the inspection. A treatment plan update was completed on November 22, 2021 and January 22, 2022; however there were no short and long term goals documented in the record at the time of this inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall within 60 days correct the lack of short term and long term goals to the appropriate documentation form. This correction shall be documented in the client form and a note placed in the operations manual. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document type and frequency on the treatment plan updates in one out of one client record reviewed.
Client #1 was admitted on December 15, 2010 and was still active at the time of the inspection. A treatment plan update was completed on November 22, 2021 and January 22, 2022; however there was no type and frequency documented in the record at the time of this inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall within 60 days examine the client's records and add a dates of service notation to this record. He will also ensure that this form is kept accurate as to dates of service |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type and support services on the treatment plan updates in one out of one client record reviewed.
Client #1 was admitted on December 15, 2010 and was still active at the time of the inspection. A treatment plan update was completed on November 22, 2021 and January 22, 2022; however there were no type and support services documented in the record at the time of this inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall within 60 days review the client file and correct any lack of information for rehabilitation services and support services that are available of offered. A note will be put in the operations manual to document that this regulation shall be followed. |