INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 9, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Addiction & Behavioral Counseling Associates 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 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 within the first year of employment in one of one counselor record.
Personnel records were reviewed on August 9, 2016. Three staff persons were employed for a time period requiring the completion of the aforementioned HIV/AIDS and TB/STD trainings. One of the staff reviewed was a counselor and was required to complete the trainings within the first year of employment.
Staff person #3 is a counselor and was hired 4/27/15. There was no documentation of TB/STD training in the personnel record for staff #3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The next available TB/STD training that will be held within a 30-mile radius will be scheduled for the employee found out of compliance with the required 4-hour minimum TB/STD training.
Individualized training plans for all employees will be used to list and track all training requirements and the Office Coordinator will be responsible for monitoring these plans to ensure all requirements are being met; with the corrected understanding that the required training must be achieved during the first year of employment as opposed to within the first training year. This correction was instated August 9, 2016.
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705.24 (1) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(1) Provide bathrooms to accommodate staff, clients and other users of the facility.
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Observations
The facility failed to ventilate bathrooms by exhaust fan or window.
A physical plant inspection was conducted on August 9, at approximately 4:30 PM. At the time of the inspection, the exhaust fan in the women's bathroom was not operable. There was no window in the bathroom.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Building maintenance was contacted and scheduled for August 26, 2016 to inspect and fix the exhaust fan in the women's bathroom. The Facility Director was responsible for contacting building maintenance, overseeing the process and ensuring it is fixed and meeting standards. This process was effective August 9, 2016, with scheduled date of August 26, 2016 to be corrected. |
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
The facility failed to document the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered, whether the smoke detector and/or fire alarm was operative, set off the fire alarm and/or smoke detector and prepare alternate exit routes to be used during fire drills.
The fire drills for the time period of September 2015 - July 2016 were reviewed on August 10, 2016. The only information documented on the fire drill logs for this time period was the date, time and person conducting the fire drill. All of the aforementioned required information was not documented on the fire drill log forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill logs have the following information added: Amount of time to evacuate; Number of persons present for the fire drill; Issues encountered; Smoke detectors operative status at the time of drill; and designation of exits that were used for evacuation. The Office Coordinator was responsible for editing this document and it was corrected and effective by August 16. 2016. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
The facility failed to document and make available to the public an annual report.
An onsite inspection was conducted on August 9, 2016. An annual report for 2015 was requested. There was no documentation of an annual report for 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A website for ABC Associates is currently being constructed and is set to launch November 2016. The Business Director will ensure an annual report will always be posted on the website for the public to access. A copy of the annual report will be made available in the office for the public to view until that time. The Business Director will be responsible for updating the annual report with the most accurate information and this will be effective November 1, 2016. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility failed to develop and implement policies and procedures to respond to unusual incidents.
The policy and procedure manual was reviewed on August 9, 2016. There was no policy and procedure documented addressing unusual incidents.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure for Reporting of unusual incidents §709.34 was added to ABC Associates Policy & Procedure Manual. The Facility Director was responsible for creating, approving, and implementing this policy into the manual. The office manager was responsible for notifying all staff of the policy update and to monitor its adherence by staff. It was corrected August 17, 2016. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
The facility failed to develop and implement policies and procedures to report to unusual incidents.
The policy and procedure manual was reviewed on August 9, 2016. There was no policy and procedure documented reporting unusual incidents.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure for Reporting of unusual incidents §709.34 was added to ABC Associates Policy & Procedure Manual. The Facility Director was responsible for creating, approving, and implementing this policy into the manual. The office manager was responsible for notifying all staff of the policy update and to monitor its adherence by staff. It was corrected August 17, 2016. |