INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 15, 2016 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.
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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
Staff CPR certification and first aid training was reviewed on September 15, 2016. Based on this review, the facility failed to ensure a sufficient number of staff person were trained in these skills were onsite during the project's hours of operation.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director shall within 90 days enroll and complete a certified CPR class and maintain the certificate in the staff records. |
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
The facility failed to 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 addition, the facility was not previously granted an exception to this regulation by the division.
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Plan of Correction
The Project director has submitted a letter requesting an exemption from an annual audit to BDAP. This letter outlines the creation of a balance sheet to fulfill a financial picture of the agency. It also states that these balance sheets shall be kept as records of the agency. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
A review of facility policies was conducted on September 8, 2016. Based on this review, the facility failed to develop and implement an Unusual Incident Policy that included procedures on how to respond to the following incidents:
(1) Physical assault or sexual assault by staff or a client.
(2) Selling or use of illicit drugs on the premises.
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
(5) Theft, burglary, break-in or similar incident at the facility.
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
(7) Fire or structural damage to the facility.
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were confirmed with facility staff during the licensing process
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Plan of Correction
The Project Director shall develop and implement an Unusual Incident Policy including and adhering to the guidelines that were put forth by BDAP. This inspection was the first time that the Project director was made aware of this new requirement and shall complete this action within 90 days of this writing. This policy shall be included in the Policy and Procedure Manual for the facility. |