INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Hispanic American Organization 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 all staff persons received a minimum of 6 hours of HIV/AIDS training within the regulatory timeframe in one of two applicable personnel records reviewed.
Employee # 2 was hired as a clinical supervisor on January 7, 2019 and was due to have HIV/AIDS training no later than January 7, 2021. The HIV/AIDS training was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The organization has develop a grid for all staff and due date to complete specific 6 hrs. of training on HIV/AIDS.
This will be closely monitor in Annual training planning.
The Clinical Supervisor will complete the
the HIV/AIDS training by June 30, 2021. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that the FTE counselor caseload in outpatient programs did not exceed 35 active clients in one of two applicable personnel records reviewed.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee #4 was hired as a counselor on January 20, 2020 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 20/40 = 0.5(FTE); 18/0.5 = 36, which equals to a client/counselor FTE ratio of 36:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The counselor case load has been reduced to 15 clients as of 4/19/2021. The 2 extra clients in caseload has been transferred to a full time employee.
The clinical supervisor will monitor the caseloads for counselors during weekly supervision to ensure they meet ration compliance and reports will be shared with the clinical director will monitor caseloads quarterly.
The organization has provided a written statement from Human Resources to clinical Supervisor/ Counselor stating that caseload of Part time of 20 hrs; may not exceeded 15 clients. |
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 the facility's May 2020 through March 2021 fire drill log, the facility failed to ensure that unannounced fire drills were conducted at least once a month. There was no documentation that a fire drill was conducted for the months of May 2020 through October 2020 and January 2021 through March 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The organization has assigned that the Cooperate compliance officer will lead the team (5 Staff) to coordinate and document the outcomes of monthly fire drills, monthly.
The Fire drills will be part of building compliance inspections monthly. The compliance officer will arrange with team for scheduling of drills. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's September 2020 through March 2021 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following the March 16, 2021 incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The organization has assigned that all incident reports will be submitted to the corporate compliance officer; that will submit electronically unusual incident report with the Department within 3 business days following an unusual incident involving: (4) Event at the facility requiring the presence of police, fire or ambulance personnel. Program director will review unusual incident reports monthly, to include continued monitoring of POC.
The program will maintain verification of all reporting file.
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