INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 30, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Central Outreach Resource and Referral Center 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 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure the fire extinguisher was inspected and approved annually by the local fire department or fire extinguisher company. At the time of the inspection, September 30, 2022, the fire extinguisher in the facility was last inspected in August 2021. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
Central Outreach Center has created the following plan of correction to deficiencies705.28 found during a site licensure renewal inspection conducted on 9/30/2022
The Program Director will ensure that fire Extinguisher be monitor a month before the due date.
To ensure that this does not recur, the Program Director will set up a reminder to contact the fire Extinguisher company to service the Extinguisher on the due date. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to document a written acknowledgment by clients they have been notified of their rights in seven of seven records.Client #1 was provided an assessment/referral on January 19, 2022.Client #2 was provided an assessment/referral on February 8, 2022.Client #3 was provided an assessment/referral on February 14, 2022.Client #4 was provided an assessment/referral on March 1, 2022.Client #5 was provided an assessment/referral on March 25, 2022.Client #6 was provided an assessment/referral on February 16, 2022.Client #7 was provided an assessment/referral on February 18, 2022.These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the September 24, 2021 annual inspection.
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Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction. found during a site licensure renewal inspection for 709.30 conducted on 09/30/2022
The Executive Director is presenting that Each client will be presented with the required client rights and will be required to sign the form acknowledging the receipt of these rights.also there will be a sign of sheet on the back of the client folder that will help for a check and balance to alleviate any reoccurs of the client right not being in the folders. The Executive Director is responsible for implementing this plan of correction |