INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17 - 18, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alpha House, 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
The facility failed to document that staff persons and volunteers received HIV/AIDS and STD/TB training.
Six staff records were reviewed on July 17, 2017. All of the staff reviewed were required to have documentation of TB/STD and HIV/AIDS training. Staff #4 and #5 did not have documentation of the required TB/STD and/or HIV/AIDS training.
Staff #4 was hired as a counselor on 2/1/16 and the TB/STD and HIV/AIDS training was due to be completed by 2/1/17. There was no TB/STD or HIV/AIDS training documented in staff record #4.
Staff #5 was hired as a counselor on 2/8/16 and the TB/STD and HIV/AIDS training was due to be completed by 2/8/17. There was no TB/STD training documented in staff record #5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff member #4 completed TB/STD/HEP on 7/31/17 at Mercy Behavioral Health. HIV is scheduled for staff member #4, 8/18/17 at Allegheny County SCA.
Staff member #5 completed TB/STD/HEP on 7/31/17 at Mercy Behavioral Health. The Executive Director is responsible for filing documentation of staff's trainings. Documentation of the trainings are located in the staff members individual training manuals. The Executive Director will file staff member #4's HIV training upon receipt of the training certificate and evidenced in the staff training file. Moving forward, all staff will have the required trainings within the timeframes specified in the regulation. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct fire drills during sleeping hours at least once every 6 months.
The fire drills for the period of July 2016 -July 2017 were reviewed. The only fire drills during sleeping hours were conducted in February & July 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Night House Monitor will be responsible for conducting no less than once every 6 months during sleeping hours a fire drill. These fire drills will occur ongoing as specified in the regulation. The Residential Director will be responsible for oversight of the completion of the fire drills during sleeping hours and the completion of the report. This report will be documented and filed with the Executive Director in the "Fire Drill Log Book". |