INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation, 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 the Project's Staffing Requirements Facility Summary Report (SRFSR), a review of personnel records, and an interview with the clinical supervisor, the facility failed to ensure that all personnel received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics training using a Department approved curriculum within the regulatory time frames.The findings include:The facility's SRFSR form was completed by the facility on 10/16/2014 and was reviewed prior to the 11/18/2014 annual licensing inspection. The facility failed to ensure that staff persons received at least 4 hours of TB/STD and other health related topics training within the regulatory time frames in one of seven personnel records reviewed, specifically, personnel record # 7. Employee # 7 was hired as a counselor on September 2, 2013. TB/STD and other health related topics training was due to be completed no later than September 2, 2014. Employee # 7 did not complete the TB/STD training prior to the one year regulatory timeframe for clinical staff.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director and clinical supervisors will ensure that newly hired staff persons receive the mandatory health related topic trainings within one year of hire. Employee #7 did not have the health related topic training completed within the first year of hire, however she received 4 hours of TB/STD training on 10/28/14 and is currently in compliance. Both the clinical supervisors and project director will monitor employee training topics and hours during monthly supervisions to ensure this does not happen again in the future. This monitoring will being on 1/5/15. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs, the facility failed to conduct unannounced fire drills at least once a month and the facility failed to prepare alternate exit routes to be used during fire drills.The findings include:A review of the December 2013 through and including the October 2014 fire drill logs was conducted prior to the November 18, 2014 annual licensing inspection and was re-reviewed with facility staff on November 18, 2014. During the months of December 2013, January 2014, February 2014, April 2014, May 2014, June 2014, July 2014, August 2014, September 2014, and November 2014, the facility failed to use alternate exit routes. The exit route used for the drills during that timeframe was the front door only. The exit route used for the fire drill in October 2014 utilized the rear exit. Additionally, the facility failed to conduct unannounced fire drills at least once a month as there was no documented fire drill during the month of March 2014.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director and clinical supervisors will ensure that all programs have monthly fire drills. The clinical supervisors will review the fire drill log sheet directions on 1/5/15, which state that fire drills must be conducted in all months, and that when conducting fire drills the program will use alternate exit routes with all staff to ensure that this deficiency does not recur. The project director will ensure ongoing compliance by having the clinical supervisors review the fire drill logs in monthly supervisions. |