INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 9, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Center For Families 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon employment in four of four applicable personnel records reviewed.Employee # 3 was hired as a counselor on May 16, 2022. The training in the use of fire extinguishers was not completed until June 19, 2022. Employee # 4 was hired as a counselor on June 20, 2022. The training in the use of fire extinguishers was not completed until July 22, 2022. Employee # 5 was hired as a counselor on October 17, 2022. The training in the use of fire extinguishers was not completed until January 3, 2023. Employee # 6 was hired as a counselor on December 12, 2022. The training in the use of fire extinguishers was not completed until January 27, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3, #4, #5, #6 all did not complete their required training on fire extinguisher usage within the needed timeframe to ensure compliance. Current onboarding now require HR to assign and guarantee trainings will be completed within 1 week of hire. This is documented on a time-stamped transcript. This completion will be monitored and internally audited.
Regional Director will be responsible for overseeing this action |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in four of four applicable personnel records reviewed.Employee # 3 was hired as a counselor on May 16, 2022. The training to perform assigned tasks during emergencies was not completed until June 19, 2022. Employee # 4 was hired as a counselor on June 20, 2022. The training to perform assigned tasks during emergencies was not completed until July 22, 2022. Employee # 5 was hired as a counselor on October 17, 2022. The training to perform assigned tasks during emergencies was not completed until January 3, 2023. Employee # 6 was hired as a counselor on December 12, 2022. The training to perform assigned tasks during emergencies was not completed until January 27, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3, #4, #5, #6 all did not complete their required training within the needed timeframe to ensure compliance. Current onboarding now require HR to assign and guarantee trainings will be completed within 1 week of hire. This is documented on a time-stamped transcript. This completion will be monitored and internally audited.
Regional Director will ensure that this action is followed up with. |