INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Christian Counseling Associates of Western Pennsylvania LLC 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) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of administrative information, the facility failed to ensure staff were instructed in the use of fire extinguishers upon employment for one of two applicable staff members.
The facility was given approval to begin services on May 8, 2023.
Employee #3 was hired on May 8, 2023 as a counselor and was still in the position as of the date of the inspection. The training was not completed as of the date of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Employee #3 will be trained on proper fire extinguisher usage by 3/1/24. Clinical Supervisor will ensure this training occurs. Clinical Supervisor will ensure all future staff will be compliant by adding this training into the onboarding process and then following up in Supervision meetings. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of administrative information, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies for one of two applicable staff members.
The facility was given approval to begin services on May 8, 2023.
Employee #3 was hired on May 8, 2023 as a counselor and was still in the position as of the date of the inspection. The training was not completed as of the date of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Employee #3 will be trained in emergency awareness and response by 3/1/24. Clinical Supervisor will ensure all future staff will be compliant by adding this training to the onboarding process and then following up in Supervision meetings. |