INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 22-24, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Abstinent Living at the Turning Point at Washington, 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
Based on a review of personnel and training records, the facility failed to provide documentation of the mandatory communicable disease training in one of five records reviewed
The findings include:
Five personnel records which required documentation of 6 hours of HIV/AIDS training were reviewed on March 22, 2016. Employee #5 was hired as an assessment coordinator on June 19, 2013, but the facility failed to provide documentation that the employee received the 6 hours of HIV/AIDS training.
These findings were reviewed with the facility staff as part of the licensing process.
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Plan of Correction
The Operations Manager confirms that Employee #5 did not have the required HIV/AIDS within the first two years of employment. The requirement for this training within the first two years has been reviewed with all applicable staff. Employee #5 is scheduled to have this training on 5/19/16. The Operations Manager and Business Manager will ensure that any future staff will have the required trainings within the first year/two years, as applicable. This will be overseen by the Project Director. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on an onsite inspection of the facility conducted on March 24, 2016, the facility failed to ensure that the grounds of the facility were free from hazards.
The findings include:
The lower portion of the facility's driveway leading into the parking lot had a patch of broken and crumpled asphalt approximately 3.5 feet wide and 3.5 feet long.
The section of the metal fence behind the green dumpster in the facility's parking lot was slumped over leaning near the ground.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
The Operations Manager confirms that there was some broken asphalt, approximately 3.5 feet by 3.5 feet, in the parking lot, which is continually broken by a garbage truck. Additionally, the Operations Manager confirms that there is a section of metal fence, owned by another individual, behind the dumpster that continually falls into the parking lot. Immediately upon inspection, the fence was repaired, to the best of our ability without permission from the fence owner. Additionally, the broken asphalt was immediately cleaned up. To ensure that there will no longer be an issue with the asphalt, we are constructing a wall by the end of May 2016 that will prohibit the garbage truck from driving on the sidewalk. In the interim, during our weekly Friday property maintenance reviews, both the fence and the asphalt will be checked and maintained as appropriate. Additionally, we will continue our efforts to contact the fence owner regarding permission to have the fence removed or permanently repaired. This will continue to be overseen by the Operations Manager and the Project Director. |