INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation Inc. 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) (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 log, the facility failed to conduct an unannounced fire drill at least once a month during one of twelve months.
The findings include:
The facility's fire drill log for the timeframe of December 2012 through November 2013 was reviewed on December 6, 2013. The facility failed to conduct an unannounced fire drill during the month of December 2012.
The Clinical Supervisor confirmed the findings.
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Plan of Correction
The project director and clinical supervisors will ensure that all programs have monthly fire drills. The clinical supervisors will review the fire drill log sheet directions on 1/6/14, which state that fire drills must be conducted in all months including summer months with all staff to ensure that this deficiency does not recur. The project director will ensure ongoing compliance by having the clinical supervisors review the fire drill logs in monthly supervisions. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the 2012 annual report, the governing body failed to make available to the public an annual report which included a statement disclosing the names of officers, directors and principal shareholders.
The findings include:
The 2012 annual report was reviewed on December 2, 2013. The facility made the 2012 annual report available to the public; however, the 2012 annual report did not include a statement disclosing the names of officers, directors and principal shareholders.
The Clinical Supervisor did not dispute the findings.
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Plan of Correction
The Project Director will make certain that the Annual Report will include a statement disclosing the names of officers and directors (there are no principle share holders). This will replace the Annual Report and will be completed by 1/15/14. The Project Director will review the Annual Report 3 months before it is available to the public to guarantee that the names of officers and directors are included, while reviewing the report the Project Director will ensure all of the components are included to be sure this deficiency does not recur. |