INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, DARS, Inc. Supervised Independent Living Program. 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 facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that staff received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Staff #7 was hired as a Youth Care Staff on December 4, 2020, and was due to have the communicable disease trainings no later than December 4, 2022. There was no documentation in the personnel record of the completion of the TB/STD training as of the date of the inspection. This finding was discussed with facility staff during the licensing process.
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Plan of Correction
Compliance with the required HIV/AIDS, and TB/STD trainings will be ensured by the Training Coordinator. Oversight of this responsibility will be gained through assessment of each employee's progress toward completion of this requirement during the employee performance evaluation, which occurs after 6 months for new employees, and on a 12 month basis for existing employees.
The Relias system will no longer be used for these training requirements and an on-site training for these topics will be held annually for all staff who have not yet completed them.
The first training is anticipated to be scheduled and held prior to Jan. 1, 2025. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection, the facility failed to light interior exits and stairs at all times.DDAP staff observed that the West stair well was only partially lit. This finding was discussed with facility staff during the licensing process.
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Plan of Correction
The light bulb in the identified light fixture was replaced on the date of inspection.
The Maintenance Supervisor will ensure that all light fixtures are operational and contain working light bulbs during a monthly facility upkeep inspection.
The Maintenance Supervisor reports directly to the Executive Director for oversight of his responsibilities. In addition to the Maintenance Supervisor's facility inspections, all facility issues/repairs needed can be submitted to the Maintenance Supervisor through an electronic work order system available on our internal computer network that is accessible by all DARS employees. |