INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 19, 2021 through January 20, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation, 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:
|
Plan of Correction
|
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.
|
Observations
The facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one applicable personnel record reviewed.
Employee #5 was hired as a counselor on June 12, 2019 and was due to have HIV/AIDS training and TB/STD training no later than June 12, 2020. The Staffing Requirements Facility Summary Report indicates that the HIV/AIDS training was completed on April 29, 2005; However, there was no completed certificate documented in the personnel record verifying the completion of the training. Additionally, the TB/STD training was completed on November 13, 2020, which was after the one year requirement.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee #5 was hired as a counselor on June 12, 2019 and was due to have HIV/AIDS training and TB/STD training no later than June 12, 2020. Employee #5 did not have a completed certificate for HIV/AIDS training in his file and did not complete TB/STD training within the first year of employment. Clinical Supervisor and HR will ensure that employees obtain the required HIV/AIDS and TB/STD trainings within their first year of hire. This will be done through regular employee file checks and having a new employee involved in an onboarding process that includes the required trainings checklist. Employee #5 will retake the HIV/AIDS training. The clinical supervisor will ensure that Employee #5 will complete the HIV/AIDS training upon the next available class. |
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.
|
Observations
The facility failed to ensure that unannounced fire drills conducted at least once a month. Based on a review of the March 2020 through December 2020 fire drill log, there were no fire drills conducted for the months of April, May, June and December 2020.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Unannounced fire drills were not conducted for the months of April, May, June and December 2020. The clinical supervisor and the building Coordinators will ensure that unannounced monthly fire drills will be conducted regardless of whether students and staff are occupying the building. The clinical supervisor and the building Coordinator will ensure that building staff are made aware of this by 2-28-2021. |