INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Diakon Child, Family and Community Ministries was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility
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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 employee training records, the facility fail to document the completion of at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training for Employee #6. Employee #6 was hired on December 17, 2013 and was to received this training by December 17, 2015.
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Plan of Correction
Preparation and submission of this plan of correction is required by State and Federal law. This plan of correction does not constitute admission for purposes of general liability, professional malpractice or any other court proceeding.
Employee #6 will have completed all required 4 hours of TB, sexually transmitted diseases and other health related topics by Sept. 1, 2016. Trainings will be scheduled by the Clinical Director and entered into the training log upon completion.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of employee training records, the facility failed to ensure that each employee was instructed in the use of the fire extinguisher upon staff employment as there was no documentation of completion for Employees #3 and 6.
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Plan of Correction
The Clinical Director will be responsible for instructing all employees in the proper use of fire extinguishers and maintain records validating the dates and staff names attending each training. This training will be provided to all new employees within the first 90 days of employment date. Employees 3 and 6 will complete training by August 30, 2016. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of employee training records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies as there was no documentation of completion for Employees #3 and 6.
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Plan of Correction
The Clinical Director will ensure that staff #3 and #6 are trained to perform assigned duties/tasks during emergencies. Documentation of tasks will be maintained in the staff training log.
The Clinical Director will incorporate fire safety and emergency training into the orientation process to ensure all new employees receive appropriate training upon hire. |
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection, the facility failed to maintain protective caps over each electrical socket in the waiting room's children play area.
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Plan of Correction
Electrical outlet covers will be purchased and installed on all outlets in the waiting room at 960 Century Drive, Mechanicsburg on or before June 20, 2016. |