INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 20, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Counseling Services 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of staff development records the facility failed to provide documentation of individual training plans in six of fifteen staff development records reviewed.
The findings include:
Nineteen personnel records were reviewed on December 17, 2013. Individual training plans were required in the fifteen records. The facility did not document individual training plans for the January 1 - December 31, 2014 training year in six records reviewed.
Person represented by personal record #1, hired July 31, 1995. An individual training plan was not completed for the 2014 training year.
Person represented by personal record #4, hired June 28, 2010, An individual training plan was not completed for the 2014 training year.
Person represented by personal record #6, hired June 1, 2007. An individual training plan was not completed for the 2014 training year.
Person represented by personal record #7, hired January 14, 2013. An individual training plan was not completed for the 2014 training year.
Person represented by personal record #12, hired December 1, 1983. An individual training plan was not completed for the 2014 training year.
Person represented by personal record #16, hired May 28, 2012. An individual training plan was not completed for the 2014 training year.
The facility director confirmed the findings.
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Plan of Correction
The citations from this audit will be reviewed at a Department Head meeting by March 31st. During the meeting, we will review the historical issues and concerns regarding individual training plans and what HR has already done to assist the managers in being compliant with this item. We will then ask for their feedback for a solution to this issue to hear and incorporate their thoughts on how the organization can be compliant in this area.
In the meantime managers have been reminded to make sure when the complete an employees performance evaluation that they enter a training plan. The Senior Director of HR is responsible for implementation.
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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 facility's staffing requirements facility summary report (SRFSR), the facility failed to ensure that staff persons and/or 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 as per the regulatory requirements in nine of twenty two staff documented on the SRFSR.
The findings include:
The facility's SRFSR form completed by the facility on December 11, 2013 was reviewed on December 20, 2013. The form listed nine staff as not having completed the mandatory training within the regulatory time frames
Employee # 8, a counselor, was hired on July 13, 2009. Employee #8 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by July 11, 2010. The training was not documented as of the date of the inspection.
Employee # 9, a counselor, was hired on February 1, 2010. Employee #9 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by February 1, 2011. The training was not documented as of the date of the inspection.
Employee # 13, a counselor, was hired on June 20, 2011. Employee #13 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by June 20, 2012. The training was not documented as of the date of the inspection.
Employee # 14, a counselor, was hired on January 9, 2012. Employee #14 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by January 9, 2013. The training was not documented as of the date of the inspection.
Employee #15, a counselor, was hired on August 20, 2012. Employee #15 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by August 20, 2012. The training was not documented as of the date of the inspection.
Employee # 16, a counselor assistant, was hired on May 28, 2012. Employee #16 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by May 28, 2013. The training was not documented as of the date of the inspection.
Employee # 20, a support staff person, was hired on September 6, 2011. Employee #20 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by September 6, 2013. The training was not documented as of the date of the inspection.
Employee # 21, a support staff person, was hired on March 30, 2010. Employee #21 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by March 30, 2012. The training was not documented as of the date of the inspection.
Employee # 22, a support staff person, was hired on May 9, 2011. Employee #22 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by May 9, 2013. The training was not documented as of the date of the inspection.
An interview with facility staff on December 20, 2013 confirmed the findings.
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Plan of Correction
All new employee files starting Jan. 1, 2014 will be audited after 6 months of hire to review all training compliance. A report will be sent to each employee and manager to coordinate scheduling and completion of the necessary trainings within a reasonable period of time.
Individuals who did not have the required trainings during this audit have been notified that they must sign up for the required trainings for HIV: 3/31/14 and Infection Control: 3/26/14.
The director of Training is responsible for implementation.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's fire drill record, the facility failed to document alternate exits during fire drills.
The findings include:
The fire drill record was reviewed on December 17, 2013. The following months were reviewed, January 2013 - November 2013. For 11 months, the facility only documented what exits were blocked and for each month the exits blocked never changed, so the exits used were the same. An interview with facility staff on December 17, 2013, confirmed the findings.
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Plan of Correction
This standard states, Fire Drills. The facility shall: (5) Prepare alternate exit routes to be used during fire drills.
(effective Jan. 2, 2014)A review was held with staff that perform the drills. They were reminded to make sure they alternate exits that are blocked and make sure the paper work adequately reflects alternate exits. Our grids and schedules will be updated to reflect which exits are to be blocked for each drill to be in compliance with the standard.
The Senior Director of Facilities is responsible for implementation and adherence.
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's fire drill record, the facility failed to document fire drills conducted during different shifts.
The findings include:
The fire drill record was reviewed on December 20, 2013. The following months was reviewed January 2013 - November 2013. The time of the latest fire drill conducted was 4:53pm. The facility offers services until 9:15pm four nights per week.
The facility director confirmed the findings
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Plan of Correction
This standard states, Fire Drills. The facility shall: (6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
CCS (outpatient)was the program that was observed out of compliance. Effective Jan. 2, 2014 our fire drill procedures have been changed to require that this program will have drills run in conjunction with all of our other programs but only between the hours of 9am and 9pm.
The Senior Director of Facilities is responsible for implementation and adherence.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's fire drill record, the facility failed to document whether the alarm or smoke detector was set off during fire drills.
The findings include:
The fire drill record was reviewed on December 20, 2013. The following months was reviewed January 2013 - November 2013. For 10 months, the facility did not document whether the alarm or smoke detector was set off during fire drills. An interview with facility staff on December 20, 2013, confirmed the findings.
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Plan of Correction
This standard states, Fire Drills. The facility shall: (7) Set off a fire alarm or smoke detector during each fire drill.
Staff that run the drills were re-trained on Jan. 2 to indicate that either a manual pull station or a smoke detector was set off for the Drill and that they need to alternate for the drills. Our forms do indicate this.
The Senior Director of Facilities is responsible for implementation and adherence. |