INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Persad Center, 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to provide a complete and accurate documentation of the qualifications and training of staff at the project's site visit.The SRFSR form was requested as part of the presubmission process; however, it was not submitted as requested. The SRFSR form was provided to the licensing specialist upon arrival at the onsite inspection; however, the form was found to be incomplete and inaccurate. Facility staff was provided with multiple opportunities to revise the form during the licensing process and multiple revisions were made. After the inspection was completed, it was reported that the information documented on the SRFSR was still incorrect. The SRFSR was signed by the project / facility director as being complete and accurate on September 4, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon receipt of the notification regarding the state audit, the Facility Director will review the pre-submission checklist and collect all relevant documentation and information pertaining to any new members of the substance abuse team. The pre-submission materials, including the checklist, will be reviewed with the Chief Operating Officer, and he will assist in the gathering of required information. Once complete, the facility director will complete the SRFSR and sign and submit by the due date. |
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 administrative information, the facility failed to ensure CPR certification and first aid training was 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 operations.Staff #3 was hired as support staff on July 28, 2025 and is CPR from April 25, 2025 through April 25, 2027. There were no other staff at the facility with CPR certification prior to July 28, 2025. The facility failed to ensure CPR certification was provided to a sufficient number of staff persons from October 2024 through July 2025.This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the September 4, 2024 annual licensing inspection.
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Plan of Correction
The facility director will review with the Chief Operating Officer the DDAP regulation that requires CPR training of staff by 9/15/25.
The facility director and one other staff designee will complete CPR and first aid training by 11/30/25.
Further, the Clinical Administrative Manager will complete CPR instructor certification by 3/31/26.
CPR and first aid training will then be provided biannually for all Persad staff. |