INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 3, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Casa De Consejeria Drug and Alcohol Counseling Program, 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:
|
Plan of Correction
|
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.
|
Observations
The facility failed to ensure that all fire extinguishers within the facility were inspected and approved annually as the date of the last inspection expired May 2019.The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The Administrative Assistant will set annual reminders for the month prior of expiration for all fire extinguishers to be serviced. Monthly check-ins will also be conducted to catch any problems with the extinguishers before the annual inspections and be serviced if needed sooner. To date, the current extinguishers have been serviced. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
|
Observations
The facility failed to include a reference to the utilization of volunteers in their current personnel management policies and procedures. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The Project Director will complete and formalize policy 709.26(a)(1) titled the Utilization of Volunteers indicating requirements, supervision, and training. The Facility Director will make sure that the policy is implemented for all program volunteers. The Administrative Assistant will also keep a smaller personnel file including background checks and trainings required when new volunteers are recruited and accepted by both the facility director and clinical supervisor. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
|
Observations
The facility failed to develop, and include with their current unusual incident policy, the specific procedures for the how the facility would monitor the corrective action plan.The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The project director has amended and revise policy 709.34, Unusual Incident Policy, to include how the facility will monitor the corrective action plan.
The revision is the following "If a corrective action plan is needed, the programs director will conduct ongoing monitoring of the plan for the necessary amount of time based on the incident reported".
The facility director will ensure that all staff is trained on the revision and implemented immediately.
|