INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Philadelphia Health Management Corporation/Chances 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 Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that staff persons and/or volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics training using a Department approved curriculum.
The findings include:
Two personnel records requiring documentation of HIV/AIDS and / or TB/STD training were reviewed on September 24, 2012. Two out of two records, specifically records # 4 and 9, did not contain the required documentation.
Employee # 4, a counselor, was hired on April 26, 2011. Infectious disease training was due by April 26, 2012. As of the date of inspection there was no documentation that employee #4 completed HIV/AIDS or TB/STD training.
Employee # 9, a counselor, was hired on August 8, 2011. Infectious disease training was due by August 8, 2012. As of the date of inspection there was no documentation that employee #9 completed HIV/AIDS or TB/STD training.
The findings were confirmed during a conversation with the Facility Director.
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Plan of Correction
The two employees who were missing their HIV and TB trainings are now scheduled to attend the TB/STD training at BHTEN on 11/2/12 and the HIV training at BHTEN on 12/17/12. Going forward, all new employees will be scheduled to attend required trainings within first or second year of hire (depending on their position) at either PHMC,BHTEN or another approved agency. In addition, management has developed an orientation form which gives the employee the information on how to register for BDAAP trainings and will provide new employees with the PHMC and BHTEN training schedules for them to register for the first available training. Management will run a report quarterly to ensure that all new hires have either taken the courses or are registered within the required timeframe. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on an inspection of the physical plant, the facility failed to ensure the hot water temperature did not exceed 120 degrees Fahrenheit.
The findings include:
A physical plant inspection was conducted on September 25, 2012 from approximately 3:41 PM. The facility failed to ensure that the hot water did not exceed 120 degrees Fahrenheit one out of four bathrooms. During the physical plant inspection, it was noted that the hot water temperature registered 124 degrees Fahrenheit in the single occupant bathroom located in the basement.
The Facility Director confirmed these findings during the physical plant tour.
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Plan of Correction
Management had asked building manager to adjust the water temperature in the lower level bathroom. This was completed on 10/8/12. Management has assigned Medical Clerk with the responsibility of measuring the water temperature monthly going forward, and logging the temperature which will be available for review. She will inform supervisor immediatly if the water temperature exceeds 120 degrees, and building management will be called to make the adjustment. |