INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on January 12 - 13, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health Center 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 employee training files, the facility failed to ensure that staff persons received at least 6 hours of HIV/AIDS training and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum.
The findings include:
One employee training file was reviewed on January 12, 2015, for documentation that staff persons and volunteers received 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.
The facility failed to ensure that employee # 2 received the required 6 hours of HIV/AIDS and at least 4 hours of TB/STD training using a Department approved curriculum within the first year of employment.
Employee # 2 was hired as a counselor on December 2, 2013, and was required to receive 6 hours of HIV/AIDS and at least 4 hours of TB/STD training by December 2, 2014.
On December 9, 2014 employee # 2 completed a 4 hour training which consisted of HIV/AIDS and STD. This training did not include tuberculosis and other health related topics; in addition, the curriculum failed to meet a Department approved curriculum.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
the unit supervisor or designee will be responsible to ensure that newly hired staff receives, within the first year of employment, a DDAP approved training curriculum for 6 hours of HIV/AIDS and 4 hours of TB and other health related topics. This training plan will be implemented within the first three months of employment and the staff will be scheduled for the first offered training. All existing unit staff needing this training will be scheduled for the next upcoming training. |
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 personnel records, the facility failed to document fire extinguisher training upon staff employment.
The findings include:
One personnel record was reviewed on January 12, 2015 to verify that staff had been instructed in the use of a fire extinguisher upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record # 1.
Employee # 1 was hired November 3, 2014. Fire extinguisher training was due upon hire; however the facility documented completion of this training on December 16, 2014.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
the unit director or designee will be responsible to ensure that the newly hired staff will receive training on the use of the fire extinguisher upon employment. This will be placed on the schedule for orientation training, which the new staff is required to complete within the first three days of the beginning of employment. The instructions given will be documented in the training binder. |