INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 16, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gentle Force Counseling Services 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:
|
Plan of Correction
|
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on a review of the facility's November 2021 through October 2022 fire drill logs, the facility failed to include documentation of the time on every fire drill log during the reviewed timeframe.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility will maintain a written fire drill record
The Facility Director will ensure that all fire drill documentation is completed monthly and will include a written record of the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered, and whether the fire alarm or smoke detector was operative.
The Clinical Director will review the agency's fire drill record binder on a regular basis to review and document that fire drills are conducted and documented accordingly.
|
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of the facility's November 2021 through October 2022 fire drill logs, the facility failed to provide documentation that the fire alarm system was in working order.
The facility has a DDAP-approved exception allowing the facility to not set off the fire alarm/smoke detector during fire drills; however, per the exception approval letter, a request was made to view documentation that the fire alarm was operational and there was no documentation provided at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will ensure that the DDAP records are updated with the building documentation of the working fire system prior to inspection.
Due to the building installing a new system this year which changed the building's point of contact for this documentation, the documentation was obtained a few days after the inspection was completed.
At this time, the agency's files are updated. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
|
Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility will maintain a written financial audit
specifically for the DDAP program by our certified public accountant for our annual financial audit activities associated with the project's drug/alcohol abuse services. An agency audit specifically for the DDAP program will be completed by March 04, 2023.
Moving forward, the financial audit will be completed by July 1st annually. The Clinical Director will ensure that the audit is completed and filed. |