INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Rehabilitation Services 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 records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that staff received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Staff #7 was hired as a Youth Care Staff on February 5, 2022, and was due to have the communicable disease trainings no later than February 5, 2024. There was no documentation in the personnel record of the completion of the HIV/AIDS training as of the date of the inspection.
Staff #8 was hired as a Youth Care Staff on May 28, 2022, and was due to have the communicable disease trainings no later than May 28, 2024. There was no documentation in the personnel record of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of this writing, the current training resource (Relias) that had provided 4 hour training for HIV/AIDS will no longer be used for this purpose.
The listed staff will be registered for a 6 hour HIV/AIDS training offered through local health providers on our facility location. The Training Coordinator has contacted local training resources to schedule an on-site training for all applicable staff.
All newly hired staff will be required to attend this training, which will be scheduled annually for all employees that have not yet completed the training.
It is anticipated that this training will be scheduled to take place prior to Jan. 1 2025.
The Training Coordinator will be responsible for ensuring that these requirements are completed with no further lapses. To oversee compliance with this requirement, completion of these trainings will be assessed as a part of the employee performance evaluation which takes place at 6 months of employment for new staff and on a 12 month basis for existing staff. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from September 2023-August 2024, the facility failed to conduct a fire drill during sleeping hours at least every six months.
There was no documentation of a fire drill being conducted, during sleeping hours, between September 15, 2023 and August 26, 2024.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
As part of the ongoing trainings required by the Youth Care Supervisor, an internal training will take place on 10/20/24 highlighting the requirements of the monthly fire drill, including the need for one overnight fire drill every six months.
The Executive Director will review the Fire Drill Training Log every 5 months to ensure compliance and to schedule an overnight fire drill if one has not yet been completed. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Staff #6 was hired on April 24, 2024, as a counselor assistant and was still in this position as of the date of the inspection. There was no documentation in the personnel record that this staff had completed this training.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The internal training checklist will be amended to include instruction on the use of fire extinguishers. Competency of this training will be demonstrated through a post-test requiring a score of 80% or more in order to begin working. The completed post-test will be placed in the employee's training file.
Compliance to this requirement will be overseen and ensured by the Training Coordinator. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Staff #6 was hired on April 24, 2024, as a counselor assistant and was still in this position as of the date of the inspection. This training was completed on June 10, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective 10/14/24, all staff, regardless of position within the agency, will be required to complete training on emergency procedures. Completion of this will be mandated within the first 30 days of employment and will be filed in the employee's training file.
Compliance and adherence to this requirement will be maintained by the Training Coordinator |