INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 31, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Milestone Centers, 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(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
The facility failed to document staff persons received TB/STD and HIV/AIDS training within the required timeframe in one of three personnel records.
Staff #3 was hired as a support staff on March 27, 2017. TB/STD and HIV/AIDS was due to be completed by March 27, 2019. There was no documentation of TB/STD and HIV/AIDS in staff record #3.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 10, 2021 annual licensing inspection.
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Plan of Correction
The Director of Quality Assurance and Compliance will provide all current staff that have not received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training with the internal curriculums approved by the Department on February 23, 2022.
All current staff will be trained in both requirements by April 29, 2022.
New staff will be trained by the training department on these requirements upon hire.
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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 fire drill logs, the facility failed to document unannounced fire drills at least once per month.
The fire drill logs were requested for the period of March 2021 through January 2022. There was one fire drill documented for the month of January 2022. There were no other drills documented for the time period reviewed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 10, 2021 annual licensing inspection.
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Plan of Correction
The Clinical Services Office Manager will be responsible for completing fire drills at least once a month and maintaining a Fire Drill Log of all monthly fire drills for on-site review.
A new annual Fire Drill Summary report was developed by the Director of Quality Assurance and Compliance to document unannounced fire drills and given to the Clinical Services Office Manager for use moving forward. Fire drills have already been completed for January and February.
The Clinical Office Services Manager will sign an acknowledgement of this requirement by March 11, 2022 |