INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
*Part 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
*Part 2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on April 28, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Asociacion Puertorriquenos en March, 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of four personnel records, it was determined that the program failed to document an annual written individual training plan for employee #1.
Employee #1 was hired September 16, 2009 and was a current employee at the time of the inspection. An annual written individual training plan was completed and signed on January 2, 2019 and the next annual written individual training plan was due no later than January 2, 2020; however, it was not documented as of the date of the inspection.
The findings were reviewed with program staff during the licensing inspection.
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Plan of Correction
Staff individual training plans will be maintained in accordance with 704.11(B). Quality Assurance and the Project/Facility director will monitor this process bi-annually to ensure compliance is met within the timelines.
The annual written individual training plan for employee #1 has been completed and submitted to the immediate supervisor. Employee #1 will obtain a signature on the completed annual written individual training plan upon return to office-based services. Moving forward, the annual written individual training plan will be submitted and approved at the anniversary of the previous plan. |
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 the review of personnel records, it was determined that the facility failed to document that staff were instructed in the use of the fire extinguisher upon employment in two of four personnel records reviewed.
Employee #2 was hired on January 2, 2020 and was a current employee at the time of the inspection. Instruction on the use of the fire extinguisher was to take place no later than January 10, 2020; however, the facility documented that the employee received the instruction on February 3, 2020.
Employee #3 was hired on February 6, 2020 and was a current employee at the time of the inspection. Instruction on the use of the fire extinguisher was to take place no later than February 14, 2020; however, the facility documented that the employee received the instruction on April 17, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will receive instruction within the use of the fire extinguisher within the first 5 business days of employment. Quality Assurance and the Project/Facility director will monitor this process at the time of hire to ensure compliance is met within the timelines.
Employee #2 and #3 have been brought into compliance. The project has changed the fire extinguisher instruction policy to reflect that it is required 7 days from the date of hire. Moving forward the project will adhere to this policy to ensure compliance maintained. |