INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services 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 five personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 4 hours of TB/STD training within the regulatory timeframe.
Employee # 5 was hired as a counselor on February 24, 2020 and was due to have the communicable disease training no later than February 24, 2021. There was no documentation in the personnel record that the training was completed at the time of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Employee #5 is registered to attend TB/STD training on 4/21/21.
Due to the pandemic, many PCS staff had difficulty completing the required trainings. The Director of Outpatient Services is currently working with the PCS Training Department to develop curriculum to be approved by DDAP so that in-house communicable disease trainings can be offered to PCS staff to ensure completion within the regulatory timeframes. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on March 8, 2021, the facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company as the fire extinguisher in the administrative office was expired as of January 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The fire extinguisher in the administrative office was inspected and approved on 3/31/21. A new tag documenting this inspection has been placed on the extinguisher.
The office manager will complete bi-annual checks of the fire extinguishers in the facility to ensure that each one has a tag showing annual inspection and approval. |