INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 17, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Colonial House, 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:
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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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that three employees received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe and there was no documentation in the employee file at the time of inspection of either training.
Employee #3 was hired as a counselor on May 10, 2021 and was due to have the trainings no later than May 10, 2022.
Employee #6 was hired as a direct support professional on August 22, 2017 and was due to have the trainings no later than August 22, 2019.
Employee #7 was hired as a direct support professional on July 19, 2019 and was due to have the trainings no later than July 19, 2021.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Under the suggestion of new Executive Director, CHI has purchased the Relias Online Training Management System, which will be implemented by 07/01/2022. Relias includes the required 6 hours of HIV/AIDS training and 4 hours of TB/STD training. All employees not in compliance will be required to complete both trainings by 08/01/2022. HR/Operations Manager will assign required trainings during onboarding process, as applicable, and will ensure all staff complete mandatory trainings in the required timeframe. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff CPR certifications, the facility failed to have at least one person trained in this skill on-site between 11pm and 7am on April 17, 2022, April 18, 2022, April 24, 2022, April 25, 2022, May 1, 2022, May 2, 2022, May 8, 2022, and May 9, 2022.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The employee who worked 11pm to 7am on the dates mentioned completed CPR training on 05/09/2022.
Operations Manager will automatically schedule support staff for CPR trainings during onboarding process, as applicable, and will monitor expiration dates.
Tech Supervisor will not schedule any support staff to work alone during their shift if not CPR certified.
A corrective action date of 05/09/2022 (date of CPR training completion) was attempted on this form but was not allowed by the system- so a corrective action date of the date of the survey was submitted. |