INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. Part 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. Part 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 1, an abbreviated off-site inspection, conducted on June 25, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.Based on the findings of Part 1, an abbreviated off-site inspection, Axiom Family 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:
|
Plan of Correction
|
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.
|
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 facility does not have first aid coverage during the following days and times:Monday from 4:00 - 5:00Tuesday from 4:00 - 7:00Wednesday from 4:00 - 7:00Thursday from 4:00 - 7:00These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
704.11(c)(2) Licensure CPR Certification
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.
|
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.
|
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.
|
Plan of Correction
705.28 (D)(4) Fire Safety
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.
|
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of nine fire drill logs provided, the facility failed to set off a fire alarm or smoke detector during each fire drill. Four fire drills indicate a verbal alarm was utilized.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
705.28 (D)(7) Fire Safety
To ensure that Axiom Family Counseling Inc., is in compliance of the fire safety regulations705.28 (D)(7) at the Jeannette's facility, it will no longer be the practice to conduct verbal fire drills. Effective 6/25/2020, the Facility Director or designated staff member selected by the Facility Director will activate a smoke alarm/detector that is located within the facility. During each random drill a different smoke alarm/detector will be activated. The Facility Director/designated staff member will indicate what smoke alarm/detector was activated during the drill and that specific alarm/detector will be recorded on the fire drill log.
|