INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 9, 2011 licensure renewal inspection. The follow-up inspection was conducted on March 27, 2012 through March 28, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, T.W. Ponessa and Associates Counseling Services, 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(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a conversation with the Facility Director, the facility failed to document an overall plan for addressing staff training needs.
The findings include:
The facility policy states: "The project director is responsible for developing the upcoming agency training plan by the close of January 31 of the New Year."
The facility was required to document an overall plan for addressing staff training needs by January 31, 2012.
On March 27, 2012, the Licensing Specialist requested a copy of the facility's overall staff training plan.
The facility failed to document an overall training plan at the time of review.
The Facility Director confirmed the findings.
This is a repeat citation. The facility was previously cited on 8/8/11 for noncompliance with this standard.
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Plan of Correction
The Facility Director met with the Project Director on 4-20-12 to discuss and plan the 2012 annual training plan. The 2012 agency training plan has been completed effective 4-27-12.
Since the training year coincides with the calendar year,the project director and the facility director will meet in early to mid January of each year to review and discuss the development of the annual training plan for that year. The project director will add it to her Outlook planning/task manager reminder for December of the previous year and January of the current year. In addition, the facility director will add it to her Outlook planning/task manager
each December and January. |
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, the facility failed to ensure that all staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training 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.
The findings include:
On March 27, 2012, one employee record requiring documentation of the required 6 hours of HIV/AIDS and at least 4 hours of TB/STD training was reviewed.
The facility failed to ensure that one of one employee received the required 6 hours of HIV/AIDS and at least 4 hours of TB/STD training, employee # 5.
Employee # 5 is a support staff member who was hired in 2005. TB/STD and HIV/AIDS training was to have been documented within two years of hire by 2007. The facility failed to provide documentation of TB/STD and HIV/AIDS training for employee #5.
The Facility Director confirmed the findings.
This is a repeat deficiency. The facility was previously cited on 8/8/11 for noncompliance with this standard.
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Plan of Correction
Employee # 5 is the Medical Director. She has completed her TB/STD and HIV training. All support staff will have 4 hours of training for TB/STD's and 6 hours of HIV training within the first 2 years of hire. The Facility Director has developed and is maintaining a spreadsheet of new support staff hires affecting the D&A Program. Information regarding dates of hire will be obtained from the Administrative Coordinator. The Facility Director will notify the Administrative Coordinator via email, when these trainings are available in the community. Support staff will register for and attend the available trainings. Utilizing the DOH Licensing approved curriculum for TB/STD's and HIV, in-house trainings will be scheduled and conducted by medical staff if support staff is unable to attend the outside trainings in the mandated time frame. The Facility Director will follow up with the Administrative Coordinator on a monthly basis to ensure that training for support staff is monitored in a timely manner. |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on observation during a physical plant inspection, the facility failed to provide an operable soap dispenser in each bathroom.
The findings include:
A physical plant inspection was conducted at 10 AM and again at 11:30 AM.
The facility failed to provide an operable soap dispenser.
It was observed that one of four bathrooms lacked an operable soap dispenser, specifically, the bathroom on the second floor.
The Facility Director confirmed the findings.
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Plan of Correction
Because the soap dispensor on the wall is new, support staff did not properly replace the soap bottle. Support staff have been trained by the Property Maintenance Supervisor on how to properly replace the soap bottle in the soap dispensor. Building staff utilizing that restroom have been instructed to notify the support staff immediately if the dispensor is not working. The support staff will have available and place a bottle of soap in the restroom if necessary. The Property Maintenance Supervisor will be responsible for replacing the dispensor if further mechanical problems arise. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the 2010 annual report and an interview with the facility director, the governing body failed to make available to the public an annual report which included a statement disclosing the names of officers, directors and principal shareholders, as required by regulation.
The findings include:
The 2010 annual report was reviewed on August 8, 2011. On July 21, 2011, the facility made available to the public the 2010 annual report. The 2010 annual report did not include a statement disclosing the names of officers, directors and principal shareholders.
On August 8, 2011, facility director was interviewed. The facility director confirmed that a statement disclosing the names of officers, directors and principal shareholders had not been included in the annual report.
This was still out of compliance at the time of the follow-up inspection.
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Plan of Correction
Moving forward for the next Annual Report due by July 31, 2012 and for all yearly subsequent Annual Reports, the Facility Director will preview the annual report and ensure that the Annual Report includes a statement which discloses the names of officers, directors, and principal shareholders. At present, the President is the sole officer of T.W. Ponessa and Associates Counseling Services, Inc. |