INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on January 9, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of staff records, the facility failed to ensure staff persons received a minimum of 4 hours of tuberculosis, sexually transmitted diseases and other health related topics within the first year of employment in one of three records.
Staff #3 was hired to the position of counselor on May 8, 2023 and was in this position at the time of review. Staff #3 was due to complete TB/STD training no later than May 8, 2024. However, staff #3 did not complete TB/STD training until January 5, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor or Facility Director will increase the frequency of auditing staff member's Bamboo HR file to ensure required training certificates are present and timely. This increase in audit frequenct will begin on 2/11/25. |
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 an inspection of facility fire extinguishers, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The facility was found to have a fire extinguisher that was last inspected in December, 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will contact the building manager by 2/11/25 to inquire about the existing policy regarding the fire extinguisher inspection process. Facility Director will follow up with buidling manager every 6 months for udpates on the fire extinguisher inspection status and related items. Fire extinguisher will be in compliance by 3/1/25. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one of two client records.
Client #1 was admitted to the outpatient level of care on November 8, 2024 and was active at the time of review. Client #1 ' s record did not contain an informed and voluntary consent form for the client ' s funder. The facility director confirmed that the facility contacted the client ' s funder regarding the client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director will add ROI's to the the list of documentation items that our Quality Assurance department audits. Facility Director will meet with Quality Assurance Supervisor by 2/11/25 to ensure this update occurs. Our facility will be in compliance by 2/11/25. Facility Director will ask by 2/11/25 for more frequent audit result updates from Quality Assurance department. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that intake procedures include documentation of a preliminary treatment and rehabilitation plan in one of two records.
Client #2 was admitted to the outpatient level of care on November 13, 2024 and was active at the time of review. Client #2 ' s record did not contain a preliminary treatment and rehabilitation plan.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will require that Counselors will send monthly updates regarding timeliness of preliminary treatment plans. Facility will be in compliance by 2/11/25. Facility Director will add preliminary and master treatment plans to the Clinical Supervision meeting agenda. |