INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 21, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Chartiers Community Mental Health and Retardation 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of applicable staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in one of one applicable records.
Staff #3 was hired as a counselor on April 22, 2024 and was still in this position at the time of the inspection. The HIV/AIDS and TB/STD trainings were to be completed by April 22, 2025. There was no documentation that these trainings were completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 19, 2024 annual licensing inspection.
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Plan of Correction
- Staff #3 will register for and successfully complete six hours of HIV/AIDS training using a DDAP approved curriculum by no later than 1/16/2026. Compliance with this action step will be monitored by Facility Director.
- Staff #3 will register for and successfully complete four hours of tuberculosis, sexually transmitted diseases and other health related topics training using a DDAP approved curriculum by no later than 3/1/2026. Compliance with this action step will be monitored by Facility Director.
- New staff who do not already possess these trainings will be registered within the first week of hire by the Facility Director.
- Compliance will be monitored weekly by Facility Director during weekly supervision.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of applicable client records, the facility failed to document a psychosocial evaluation in four of six records.
The facility ' s policy states the psychosocial evaluation must be completed at intake.
Client #2 was admitted on April 4, 2025 and was still active at the time of the inspection. A psychosocial evaluation was not documented at the time of the inspection.
Client #3 was admitted on April 29, 2025 and was still active at the time of the inspection. A psychosocial evaluation was not documented at the time of the inspection.
Client #5 was admitted on December 18, 2024 and was discharged on February 25, 2025. A psychosocial evaluation was not documented at the time of the inspection.
Client #7 was admitted on May 6, 2025 and was discharged on June 24, 2025. A psychosocial evaluation was not documented at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
- By 12/31/2025, Facility Director will audit all active charts and identify clients who lack a psychosocial evaluation.
- Counselor will complete psychosocial evaluation for any client who does not have one documented in their chart. All active clients will have a psychosocial evaluation in their chart by 2/1/2026.
- Beginning 12/1/2025, staff will successfully complete psychosocial evaluations for 100% of all new intakes.
- Compliance will be monitored on a weekly basis by Facility Director during individual supervision.
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