This report is a result of an on-site licensure renewal inspection conducted on March 25, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mainstream Counseling, 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
|
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 employee #8 received the minimum of at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #10 was hired as a support professional on November 22, 2021, and was due to have the TB/STD trainings no later than November 22, 2023. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
- At the conclusion of the inspection, clarification was sought and received from DDAP Licensing Specialist regarding the timeframe calculation for new employee mandatory trainings.
-Initial review of inspection findings in post-inspection Administration meeting on 03/26/24, along with discussion of potential procedural changes needed to ensure compliance.
-On 3/27/24 the Director met with the identified Support professional to review the deficiency. During that meeting the Director assisted this staff member with signing up for TB/STD training. The staff member is currently scheduled to attend this mandatory training on 04/30/24.
- On 04/02/24 the Executive Director and Director met to develop a new procedure to ensure all new Counselors and Counselor Assistants receive the Mandatory Communicable Disease trainings within the first year of employment and all other staff within the first 2 years of employment. A new employee training monitoring tool has been developed and will be implemented immediately. Upon hire, all new employees will receive a list of DDAP and other regulatory agency mandatory trainings and will identify the regulatory timeframe(s) in which they must be completed.
|