INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 24, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Spring-Ford Counseling Services, 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 employee #2 received at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee # 2 was hired as a counselor on 7/1/12 and was due to have at least 4 hours of TB/STD and other health related topics training no later than 7/1/13. There is no documentation in the personnel file of the completion of the required TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Within 60 days, Employee #2 will attend at least 4 hour training for TB/STD, Executive Director will monitor training requirement. |
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 a physical plant inspection conducted on October 24, 2017 at approximately 2:30 pm, it was determined that the facility failed to illuminate the following emergency exits at all times:
1.The exit sign over the front entrance.
2.The exit sign over the back exit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To date, Landlord, Michael Rittenhouse, has been notified and has inspected Exit signs. Within 30 days exit sign over front door and exit sign over back exit will be illuminated, overseen by Executive Director. Executive Director will continually monitor illuminated lighting and if it malfunctions or no longer works Executive Director, Louisa Pieri, will notify landlord immediately and ensure lighting is fixed in an timely manner. |