INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on May 20, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Christian Counseling Associates of Western Pennsylvania 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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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to document a mechanism to provide feedback on completed trainings in one of two records.
The facility policy and procedure manual indicated that staff are to complete a feedback form after each training is completed.
Staff #1 was hired as project director October 9, 2024. No training feedback forms were completed for the 2025 trainings.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will meet with the Project Director on 6/22/26 and review this policy. Project Director will add this item to our Monthly Executive Supervision meeting to ensure compliance. Facility will be in compliance by 6/22/26. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to develop a written individual training plan for each employee in one of two records.
Staff #1 was hired as project director October 9, 2024. There was no documentation of an individual training plan for the 2026 training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will meet with Project Director on 6/22/26 about the importance of completing individual training plans. Individual training plans will be added to the agenda for our Executive Staff Quarterly meetings to ensure plans are completed by all staff. Facility will be compliant by 6/22/26. |
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 fire drill records, the facility failed to conduct unannounced fire drills once a month.
No fire drills were conducted between June 2025 to April 2026.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the June 30, 2025 annual licensing inspection.
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Plan of Correction
Facility Director will ensure fire drills are being conducted and recorded. Fire drills will be completed monthly by Facility Director. Project Director will hold Facility Director accountable to complete fire drills. Facility will be compliant by 6/30/26. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel are trained to perform assigned tasks during emergencies in two of two records.
No current employees are trained to perform assigned tasks during emergencies at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the June 30, 2025 annual licensing inspection.
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Plan of Correction
Facility Director will provide training on emergencies by 6/30/26. Facility Director will provide proof of training completion via certificate. Facility will be compliant by 6/30/26. |