INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 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.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 2, an abbreviated on-site inspection, conducted on March 31, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Axiom Family Counseling Services was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Therefore, deficiencies were identified during this inspection and a plan of correction is required.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
During a review of nine personnel on June 25, 2020, the facility failed to ensure CPR certification and First Aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation. The faciltiy does not have coverage during the following days and times: Monday, from 5-6 pmTuesday, from 5-6 pmWednesday, from 5-6 pmThursday, from 5-6 pmThese findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.11(c)(2) Licensure CPR Certification
This citation was approved on 7/7/2020 during the first part of the licensing inspection. The project manager will train the facility director on how to accurately report drug and alcohol facility hours and will review required DDAP licensing paperwork before submission for accuracy. To ensure that there is sufficient FA/CPR trained staff to cover all hours of operations, the facility director will schedule at least two staff who are trained in FA/CPR during those hours of operation. On July 30, 2020 Axiom is having an all staff training on FA/CPR training.
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility's work week. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.Employee #5 was hired on May 5, 2019 and was still acting in that position. Employee #5 was reported to have 10 hours per week devoted to their 9 clients on their caseload.The FTE counselor's caseload calculation is as follows: 10/40 = .25(FTE); 9/.25 = 36, which equals to a client/counselor ratio of 36:1.Employee #4 was hired as a counselor on January 6, 2020 and was still acting in that position. Employee #4 was reported to have 9 hours per week devoted to their 9 clients on their caseload.The FTE counselor's caseload calculation is as follows: 9/40 = .225(FTE); 9/.225 = 40, which equals to a client/counselor ratio of 40:1.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.12(a)(6) OutPatient Caseload:
The Facility Director will review the active client case loads on a weekly basis to ensure that Axiom Family Counseling Inc., is compliant with the 35 to 1 ratio.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of nine fire drill logs provided, the facility failed to include problems encountered during the fire drill on the facility fire drill log. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (D)(4) Fire Safety
This citation was approved on 7/7/2020 during the first part of the licensing inspection. To ensure that Axiom Family Counseling Inc., is in compliance with the fire safety regulations 705.28 (D)(4) at the Jeannette facility, a new fire log was developed on 6/25/2020 and will replace the existing fire log. The new fire log indicates if there were any "problems encountered" during the evacuation of the facility. If there are identified issues, it will be stated on the log and a plan of correction will be developed correct such issues.
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