INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 8, 2019 of LaRocco Counseling by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, LaRocco Counseling 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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #11 received the minimum of at least 4 hours of TB/STD training within the regulatory timeframe.
Employee #11 was hired as clerical staff on 11/10/2015 and was due to have the communicable disease trainings no later than 11/10/2017. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #11 has completed the required training since inspection. In addition, starting Feb 2019, Project Director will monitor to ensure all new staff are receiving this training within the stipulated time frame. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, 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 and whether the fire alarm or smoke detector was operative.
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Observations
A review of the February 2017 through January 2019 fire drill logs was conducted during the onsite inspection. The facility failed to document the length of time it took to evacuation in the fire drills conducted on December 12, 2018 and December 27, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting Feb 2019, the Project Director will monitor fire drill logs to ensure all information is logged accurately and all areas are addressed and completed. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to ensure that clients were made aware of all of their client rights in records #1, 2, 3, 4, 5, 6 and 7. The signed acknowledgement of client rights in the client records failed to notify clients that they may not be discriminated against based upon their color.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director created an addendum on 2-8-19 to be signed by all active clients at next scheduled session informing them that LaRocco Counseling Inc does not discriminate based on color. In addition, client rights paperwork has been updated informing new clients that LaRocco Counseling Inc does not discriminate on the basis of color. |