INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 29, 2011 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on May 3, 2011.
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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 facility's training documentation, the facility's sole proprietor failed to provide documentation of hands on CPR certification and training. The findings include:A licensing inspection was conducted on March 29, 2011. The sole proprietor provided a copy of a CPR certification from ProCPR with an expiration date of November 2012. This was a result of an online training which did not involve hands on application. The sole proprietor did not have documentation of face to face training, but did produce proof of registration for a hands on CPR training on April 20, 2011. The sole proprietor verified that the ProCPR certification was a result of an online training.
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Plan of Correction
The Project Director was slated to attend a CPR training session of April 20, 20111 for certification. The traing was rescheduled for May 25, 2011 because here were not enough registered participants for theoriginal date. The project director will attend the rescheduled traing and receive certification in CPR with hands-on traing. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the facility's documents, the facility's sole proprietor was not able to produce evidence of instruction in the use of the fire extinguisher.The findings include:A licensing inspection was conducted on March 29, 2011. The sole proprietor was asked to provide documentation of training and/or instruction in the use of the fire extinguisher. The sole proprietor stated that he did not have the documentation.
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Plan of Correction
In the week following the BDAP inspection the Project Director contacted Nittany Realty Management the owner of 103 East Beaver Ave. about this issue. Nittany Realty instructed the Project Director to contact the building's maintenance man for instruction on the proper use of the buildings fire extinquishers. The maintenance man gave a hands-on demonstration of the required steps to operate the standard fire extinquishers installed throughout the building. The Project Director feels that the demonstration and discussion has adequately prepared him to operate all of the publically accessable fire extiquishers in the building. The Project Director will include within the P&P Manual a signed copy by the appropriate trainer documenting the date and substance of training. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill logs, the facility's sole proprietor failed to provide documentation that fire drills had been conducted at least once per month.The findings included:A licensing inspection was conducted on March 29, 2011. The facility's sole proprietor was asked to provide documentation of the fire drills conducted over the last six months. The sole proprietor produced a list of fire drills that had been conducted between August 2008 and January 2010. The sole proprietor was asked for the fire drill log from November 2010 to February 2011. The sole proprietor could not provide that document during the inspection and stated that a copy would be forwarded by April 8, 2011. The sole proprietor faxed the fire drill list of fire drills conducted between August 2008 and January 2010. The fire drill log for drills conducted between November 2010 and February 2011 was not produced.There was no documentation demonstrating that fire drills had been conducted at least once per month.
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Plan of Correction
A copy of the updated (11/10-2/11) fire drill log was found subsequent to the faxing of the documents on April 8 and has been included in the Facility's Policy and Procedure Manual with appropriate updates included.
A copy of the monthly fire drill log shall be placed in the P&P Manual and shall be updated on a monthly basis.
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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 fire drill material provided by the facility's sole proprietor, the facility failed to maintain a written record of fire drills conducted between November 2010 and February 2011.The findings include:A licensing inspection was conducted on March 29, 2011. The facility's sole proprietor was asked to provide documentation of the fire drills conducted over the last six months. The sole proprietor produced a list of fire drills that had been conducted between August 2008 and January 2010. The sole proprietor was asked for the fire drill log from November 2010 to February 2011. The sole proprietor could not provide that document during the inspection and stated that a copy would be forwarded by April 8, 2011. The sole proprietor faxed the fire drill list of fire drills conducted between August 2008 and January 2010. The fire drill log for drills conducted between November 2010 and February 2011 was not produced.The facility did not maintain a written record of fire drills conducted between November 2010 and February 2011.
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Plan of Correction
A copy of the updated (11/10-2/11) fire drill log was found subsequent to the faxing of the documents on April 8 and has been included in the Facility's Policy and Procedure Manual with appropriate updates included. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on as review of the facility's administrative material and reports, the facility's sole proprietor was not able to provide a copy of the goals and objectives for fiscal year 2011.The findings include:An on site licensing inspection was conducted on March 29, 2011. The sole proprietor was asked to provide a copy of the goals and objectives for the 2011 fiscal year. The sole proprietor was not able to provide the requested goals and objectives.
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Plan of Correction
The Project Director is in the procsess of reviewing the goals and objectives for the 2011 fiscal year. This review is contingent upon possible clientele population changes and the desire to provide more efficient services by the possible addition of staff or incorporation of the facility. All of these issues should be resolved within 90 days and a statement posted in the P&P manual reflecting the revised gaols and objectives that are resolved. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
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Observations
Based on a review of materials provided, the facility failed to produce documentation of written letters of agreement or understanding with primary referral sources.The findings include:A licensing inspection was conducted on March 29, 2011. The facility's sole proprietor was asked to provide copies of written letters of agreement or understanding with the facility's primary referral sources. the sole proprietor was unable to provide copies of those documents.
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Plan of Correction
A request was made in April 2011 to The Mount Mittany Medical Centre's Pain Management Clinic for a letter of agreement and understanding. They agreed to send one but as of this writing the Project Director has not received the physical copy. A follow-up phone call will be made to the Clinic on Monday May 16th to inquire as to the progress of the document. Bi-weekly contact is maintained with the facility in reference to common clients. When the letter is received it will be placed on the P&P Manual. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of the facility's administrative material, the facility's sole proprietor was unable to provide a copy of the written agreement, with a licensed hospital or physician, for 24 hour emergency psychiatric and medical coverage.The findings include:A licensing inspection was conducted on March 29, 2011. The sole proprietor was asked to provide a copy of the written agreement for 24 hour emergency psychiatric and medical coverage. The sole proprietor could not provide a copy of the agreement.
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Plan of Correction
A request was made in April 2011 to The Mount Mittany Medical Center for a letter of agreement and understanding for 24 hours emergency psychiatric and medical coverage through appropriate referral to the hospital for these services. They stated that they would have to retrieve and review the agreement that was previously in effect and still is in agreement between Mount Nittany Medical Center (then known as the Centre County Hospital)and Walter B. Morrison M.Ed.,LPC (DBA)as Centre Counseling Associates. They stated that this woud be done and agreed to send a new letter but as of this writing the Project Director has not received the physical copy. A follow-up phone call will be made to the hospital on within the next several weeks to inquire as to the progress of the document. When the letter is received it will be placed on the P&P Manual. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of the facility's administrative materials, the facility's sole proprietor failed to provide a copy of the annual audit for the fiscal year January 1, 2009 through to December 31, 2009.The findings include:A licensing inspection was conducted on March 29, 2011. The sole proprietor was asked to provide a copy of the annual audit for the fiscal year ended December 31, 2009. The sole proprietor indicated that there was no audit for 2009.
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Plan of Correction
The Project Director will send via U.S. Mail a second copy of the the letter which was originally dated 9/20/10 to the appropriate address at the Licencing Division within 4 weeks.
If this request should be rejected the plan of correction is to detail that: The Project Director is the only individual associated with the facility. The facilty is under a Sole Proprietorship type of ownship. The Project Director is the Sole Proprietor, the facility receives no County, State, nor any type of Public funding. The total of all funds to the Facility is and always has been under $500,000. The Project Director can and will provide a W-9 Form and appropriate 1099 Forms to document this fact. The exception request will be submitted in accordance with the licensing alert. If the request should be denied then an audit shall be conducted for 2009.
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709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
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Observations
Based on a review of the facility's policy and procedure regarding client rights, the facility failed to provide a procedure describing how portions of the record will be removed prior to a review by the client.The findings include:A licensing inspection was conducted on March 29, 2011. The policy and procedure on client rights was reviewed. The procedure for removing portions of the client's file prior to the review of the file by the client was not included. The sole proprietor was not able to provide copy of that procedure.
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Plan of Correction
The Project Director shall include in the P&P manual the procedure for removing portions of the client's file prior to the review of the file by the client. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's administrative policy and procedure, the facility's policy and procedure on client follow up failed to indicate that at least one follow up attempt would be conducted on all clients who leave treatment.The findings include:A review of the client follow up policy for those clients who leave treatment failed to address clients who do not successfully complete treatment and leave treatment against facility advice. The current policy only indicates that follow up contact will be attempted three months after successful completion of treatment.
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Plan of Correction
A statement shall be included in the P&P Manual that when a client leaves treatment after an unsuccessful course of treatment or against facility advice an attempt via phone to contact the client for a follow-up be made no later than 90 days postdischarge. The attempt will be made using the phone information on the intake form unless other information has been received and documented. |
709.94(f)(1) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(1) Identifying persons in need of project services.
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Observations
Based on a review of the facility's administrative reports and documents, the facility failed to provide a copy of the outreach plan.The findings include:The licensing inspection was conducted on March 29, 2011. The facility's sole proprietor was asked to provide a copy of the outreach plan. The sole proprietor could not produce a copy of the outreach plan.
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Plan of Correction
The Project Director is in the procsess of reviewing the outreach plan involving the outreach goals andobjectives for the 2011 fiscal year. This review is contingent upon possible clientele population changes and the desire to provide more efficient services by the possible addition of staff or incorporation of the facility. All of these issues should be resolved within 90 days and a statement posted in the P&P manual reflecting the revised gaols and objectives that are resolved. |