INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Guidance Center 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, the facility failed to document HIV/AIDS training in one of two personnel records.
The findings include:
Five personnel records were reviewed on May 28, 2015. Two personnel records were reviewed for documentation of HIV/AIDS and TB/STD training. The facility failed to provide documentation of the required HIV/AIDS training in personnel record # 5.
Employee # 5 is a counselor and was hired on January 1, 2014. HIV/AIDS and TB/STD training was due to be completed no later than January 1, 2015. The facility failed to provide documentation of HIV/AIDS training as of May 28, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Said therapist #5 attended the training 5/13/15. The Outpatient Director missed the documentation on the staffing form and will ensure correct documentation in the future. All future staff/new hires will be scheduled for the required trainings in the first week of hire by the Director of Outpatient. |
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 fire drill records, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
Fire drill records for June 2014 through April 2015 were reviewed on May 28, 2015. The facility failed to conduct unannounced fire drills for the months of June 2014 and August 2014.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A schedule for fire drills will be made to encompass requirements. Follow up will occur by the outpatient director to ensure they have occurred each month by the 15th. |