INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on June 30, 2025 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 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills once a month.
No fire drills were conducted between December 2024 to May 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Director will ensure that unannounced fire drills are conducted monthly by following up with Counselor and Facility Manager at ECM. This follow up will occur during last week of each month. Facility will be in compliance by 8/22/25. |
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 personnel records, the facility failed to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies in two of two records.
No current employees were trained to perform assigned tasks during emergencies at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Director will ensure that emergency training is added to the onboarding protocol. Director will meet with Admin who does onboarding by 8/22/25. Facility will be in compliance by 8/22/25. Current staff who do not have emergency training will be trained in emergency training by 8/22/25. |