INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 22-23, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A Better Today, 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, the facility failed to ensure that staff persons and / or volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics training using a Department approved curriculum.
The findings include:
Three personnel records requiring documentation of HIV/AIDS and / or TB/STD training were reviewed on November 22, 2011. Two out of three records, specifically record #s 3 and 4, did not contain the required documentation. Employee # 3, a counselor, was hired on July 6, 2010. Employee # 4, a counselor, was hired on September 27, 2010.
As of November 22, 2011, there was no documentation that employee #s 3 and 4 completed HIV/AIDS and TB/STD training.
The findings were confirmed during the exit interview with the Clinical Director.
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Plan of Correction
Employee #3 is no longer employed by ABT. Employee #4 is employed as a part time/on call counselor. Employee #4 is pursuing outside HIV/STD training. The current full time Hazleton employee is currently certified in HIV/STD. A training is currently scheduled in April 2012 at ABT's central office for all ABT employees who require HIV/STD training. The Project Director is responsible for assuring that all ABT employees have received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD at the time of hire or before they are permitted to work alone in any ABT facility. Based on this policy, the opportunity for this deficiency to occur again is eliminated. |
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based upon a review of the Staffing Requirements Facility Summary Report (SRFSR) and training records, the facility failed to ensure that staff members had obtained at least half of their required training hours by trainers not directly employed by the project.
The findings include:
On November 22, 2011, the SRFSR and four staff training records were reviewed for the January 1, 2010 through December 31, 2010 training year. The facility failed to ensure that at least half of the required training hours was provided by trainers not directly employed by the project in one of two records reviewed, specifically record #1. While the SRFSR listed all employees of the facility and common employees of the project, it did not include a listing of any trainers who are employed by the project for the primary purpose of providing training.
The SRFSR and employee #1's training record showed that employee #1 obtained 16 hours of in-house training in 2010, but did not obtain any external training hours as required. Employee #1, the Project Director was required to complete 12 hours of training for the training year, half of which were required to be provided by outside trainers.
The Clinical Director confirmed the findings during the exit interview.
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Plan of Correction
ABT's administrative and clinical training program was updated and revised, by the Project Director, on November 18, 2011. To date, all ABT staff members have met, or exceeded, the required training hours by both internal and external trainers. In each case, more than one half of each employee's training hours have been provided by external trainers. In 2012, the Project Director will schedule monthly in-service trainings for all ABT staff members. As of this date external PCB/BDAP approved trainings have been scheduled to ensure compliance with the Department's regulation regarding staff training. The Project Director is responsible for all internal and external staff training schedules on an annual basis. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on the physical plant inspection, the facility failed to ensure that ventilation was provided in all bathrooms.
The findings include:
The physical plant inspection was conducted on Nov. 23, 2011, at approximately 3:00 PM. The project's Clinical Director and the facility's primary counselor accompanied the Licensing Specialist during the inspection. The facility provides two bathrooms for clients, staff and visitors. One of two bathrooms, the bathroom located just off the main group room, did not contain an external window or operable exhaust fan.
The findings were confirmed by the Clinical Director and primary counselor during the exit interview.
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Plan of Correction
ABT leases the Hazleton office space from Hazleton General Hospital. The ABT project director is responsible for correcting this problem. The Hospital administration has been contacted on several occassions to correct the non-compliance licensure regulation regarding bathroom ventilation. ABT has contacted the hospital administration and, again, requested that this matter be corrected. ABT is currently pursuing new office space with the intention of moving the Hazleton office into a facility with structual compliance to ADHS regulations. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on the physical plant inspection, the facility failed to keep all interior exits lit at all times.
The findings include:
The physical plant inspection was conducted on Nov. 23, 2011, at approximately 3:00 PM. The Clinical Director and primary counselor were present for the inspection. Four interior exits were inspected for lighting. One of four exits, the rear exit, was not lit during the inspection. Neither the lights in the hallway leading up to the exit nor the light above the exit itself could be turned on. The primary counselor confirmed that the lights in the hallway leading up to the exit had not worked for some time.
The findings were re-confirmed during the exit interview with the Clinical Director and the primary counselor.
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Plan of Correction
On November 23, 2011, new lights were installed in the rear exit hallway bringing ABT into compliance regarding this regulation. Hazleton General Hospital, by lease, is responsible for all problems in the physical plant. However, the hospital administration has been deficient in this responsibility. ABT has, and will, assumed responsibility for physical plant maintainance. ABT is currently pursuing new office space in Hazleton with the intention of moving the Hazleton office. |
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on the physical plant inspection, the facility failed to maintain at least one operable smoke detector.
The findings include:
The physical plant inspection was conducted on Nov. 23, 2011, at approximately 3:00 PM. The project's Clinical Director and the facility's primary counselor accompanied the Licensing Specialist during the inspection. No smoke detectors could be found inside the facility.
The findings were confirmed by the Clinical Director and primary counselor during the exit interview.
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Plan of Correction
On November 23, 2011, two new smoke detectors were installed in the group room and hallway bringing ABT into compliance regarding this regulation. ABT has, and will, assumed responsibility for physical plant maintainance. The ABT project director will check the funtion of all smoke detectors on a monthly basis during fire drills. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill log and dialogue with the primary counselor, the facility failed to set off a fire alarm or smoke detector during monthly fire drills.
The findings include:
The physical plant inspection was conducted on November 23, 2011, which included a review of the facility's fire drill log. As per the log, monthly fire drills were conducted on the following dates and at the following times. The fire drill log failed to include documentation that either a fire alarm or smoke detector was used during 4 of 12 monthly drills.
Nov. 3, 2011, at 1:30 PM - Fire Alarm or Smoke Detector Used: No
Oct. 5, 2011, at 2:00 PM - Fire Alarm or Smoke Detector Used: Yes
Sept. 13, 2011, at 3:00 PM - Fire Alarm or Smoke Detector Used: Yes
Aug. 18, 2011, at 6:45 PM - Fire Alarm or Smoke Detector Used: Yes
July 19, 2011, at 4:00 PM - Fire Alarm or Smoke Detector Used: No
June 29, 2011, at 1:00 PM - Fire Alarm or Smoke Detector Used: Yes
May 16, 2011, at 2:30 PM - Fire Alarm or Smoke Detector Used: Yes
April 22, 2011, at 7:30 PM - Fire Alarm or Smoke Detector Used: No
March 22, 2011, at 6:15 PM - Fire Alarm or Smoke Detector Used: Yes
Feb. 15, 2011, 4:30 PM - Fire Alarm or Smoke Detector Used: Yes
Jan. 13, 2011, at 1:45 PM - Fire Alarm or Smoke Detector Used: Yes
Dec. 15, 2010, at 1:30 PM - Fire Alarm or Smoke Detector Used: No
The primary counselor confirmed the findings at the end of the physical plant inspection.
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Plan of Correction
As a solution to the difficulty in securing a waiver for the Department's fire alarm regulation, as of January 31, 2012, ABT changed the Hazleton fire drill policy by beginning to use the manual alarm feature on the smoke detectors already installed at the Hazleton location. This new fire drill procedure will allow the facility to manually sound and respond to the fire alarm. The Project Director is responsible for conducting monthly fire drills that are consistent with the Department's regulation. All fire drills will be documented in an annual report that will be presented to the department upon request. This change in policy will ensure ABT's compliance with the Department's fire drill regulation. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based upon a review of the project's annual report, the project failed to include all the required elements in its annual report.
The findings include:
The project's annual report was reviewed on Nov. 14, 2011. The annual report did not include a financial statement of income and expenses.
The Project Director confirmed the findings during the exit interview conducted on Nov. 16, 2011.
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Plan of Correction
The Project Director will ensure that the project's annual report will include a statement of income and expenses. The 2010 statement of income and expense has been filed in the 2010 annual report and the 2011 annual report is currently being prepared and will include the 2011 income and expense report. In the future the Project Director will assure that a statement of income and expenses is bound with the annual report to assure it is readily available to the public. All annual reports are also advertised in local newspapers. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based upon a review of the project's annual report, the project failed to include all the required elements in its annual report.
The findings include:
The project's annual report was reviewed on Nov. 14, 2011. The annual report did not include a disclosure of the project's officers, directors, and/or principal shareholders.
The Project Director confirmed the findings during the exit interview conducted on Nov. 16, 2011.
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Plan of Correction
By 01/15/2012, the project director will disclose in the 2011 annual report the project's officers and directors. The disclosure of the project's officers and directors are currently filed in the 2010 annual report. During the inspection, the listing of the project's officers and directors was available, but was misfiled. In the future the listing of the project's officers and directors will be bound with the annual report so misfiling cannot occur. |