INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29-30, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Fayette County Drug and Alcohol Commission 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 and a plan of correction is due on July 24, 2009.
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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 the personnel and training records on June 29, 2009, the facility failed to provide the required documentation of 6 hours of HIV/AIDS training in one of eight records.
The findings include:
Ten personnel and training records were reviewed on June 29, 2009. Six hours of HIV/AIDS training were required in eight personnel and training records. One support staff, personnel and training record #10, did not have the 6 hours of HIV/AIDS training within the first two years of employment. The staff member was hired May 7, 2007, and the training was due by May 7, 2009, but the training was not completed.
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Plan of Correction
The support staff whose personnel and training record was #10, is scheduled to take Basic HIV (6 hours) at the Pittsburgh Marriott North on Tuesday, November 17, 2009. |
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.
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Observations
Based on a review of the fire drill records and a discussion with the facility director on June 29, 2009, the facility failed to complete a fire drill for the month of October 2008.
The findings include:
Fire drill records from July 2008 to June 2009 were reviewed on June 29, 2009. Fire drills are required monthly. The facility did not complete or document a fire drill for the month of October 2008.
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Plan of Correction
FCDAC will ensure that fire drills are completed and documented on a monthly basis. The Treatment Program Manager will review this documentation with the Administrative Assistant on a monthly basis. |
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 the personnel and training records and a discussion with the facility director on June 29, 2009, the facility failed to document that all personnel on all shifts are trained to perform assigned tasks during emergencies in five of five client records.
The findings include:
Ten personnel and training records were reviewed on June 29, 2009. Five personnel and training records were reviewed for documentation of training to perform assigned tasks during emergencies. Records #1, 2, 3, 4, and 5 did not include this documentation.
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Plan of Correction
FCDAC will provide training on performing assigned tasks during emergencies to all staff on August 28, 2009. All staff will read FCDAC's Disaster Plan, and sign a form stating they understand their assigned tasks during emergencies. Additionally, all new staff hired after 7-1-09 will review FCDAC's Disaster Plan as part of their new employee orientation and will sign a form stating they understand their assigned tasks during emergencies. This orientation will occur within 7 days of hire. |