This report is a result of a licensure renewal inspection. The client record review was conducted January 22, 2024, and a physical plant inspection conducted on January 24, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the annual inspection, Pennsylvania Counseling Services Lancaster City 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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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one of fourteen records.
Employee # 13 was hired by the facility on September 18, 2023, and was appointed to a counselor position on September 20, 2023. Employee #13 began working shifts prior to being trained to perform assigned tasks during emergencies. Training to perform assigned tasks during emergencies was not documented to have occurred until October 5, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Quality Improvement provided re-education to the PCS Human Resources Department on February 6, 2024 that all drug & alcohol personnel on all shifts must be trained to perform assigned tasks during emergencies. The Human Resources Department will ensure ongoing compliance by reviewing the completion of necessary training documentation prior to end of staff orientation. |