Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
Part 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
Part 2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on April 13, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Spanish American Civic Association for Equality, 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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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 employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired on March 12, 2018 and was still employed at the time of the inspection. The facility failed to ensure that the employee completed the mandatory HIV/AIDS and TB/STD trainings within the required timeframe per the regulation. While the facility director indicated that the employee had been laid off in March 2019 and brought back on September 2019, the facility had not terminated the employee and was still having the employee attend trainings as documented in the personnel record.
Employee #4 was hired on January 6, 2019 and was still employed at the time of the inspection. The facility failed to ensure that the employee completed the mandatory four hours of TB/STD trainings within the required timeframe per the regulation.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To correct this deficiency the employee will attend the required training within the next 30 days. To ensure compliance the clinical supervisor will review training calendar quarterly to ensure compliance. Program director will review semi annually to ensure process is being completed. |