INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20-21, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alpha House Inc. 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 of 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 five personnel records.
The findings include:
Five personnel records were reviewed on May 20-21, 2015. Five personnel records were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training in personnel record # 3.
Employee # 3 was hired as a counselor on August 19, 2013. The HIV/AIDS and TB/STD training's were due to be completed by August 19, 2014. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of May 21, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 will receive HIV/AIDS training as well as TB/STD training within the next 30 days from submission of the POC to DOH. The Executive Director will be responsible for the TB/STD training following the approved DDAP curriculum as cited on Licensing Alert 6-97, Training Outline. Documentation will evidenced in the Employee#3 Training record. Employee#3 is currently scheduled for HIV/AIDS training scheduled June 26, 2015 through an approved DDAP trainer. Documentation will be evidenced in Employee #3 training record. All new employees will be required to take HIV/TB/STD training as part of their orientation within the first 6 months of employment with Alpha House to prevent reoccurrence. An approved DDAP trainer will be utilized and in some instances the Executive Director will be responsible using the approved DDAP curriculum for instruction. Documentation will be evidenced in the employee's training manual and on the orientation of new employee's sign off sheet. The Executive Director will ensure that the training will occur with all new employees. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill logs, the monthly unannounced fire drills failed to document that fire drills were conducted at least once every six months during sleeping hours and the exit route used.
The findings include:
The fire drill logs, for the period of June 2014 through April 2015, were reviewed on May 20-21, 2015. The facility's sleeping hours are from 11:15 PM to 7:30 AM during the week, and 11:30 PM to 7:30 AM on the weekends. The facility did not document any overnight fire drills during sleeping hours from June 2014 to April 2015.
The facility conducted fire drills on 6/17 and 6/26/2015. The exit route used was not completed on the drills conducted.
The facility conducted fire drills on 7/25 and 7/29/2015. The exit route used was not completed on the drill conducted on July 25, 2014. The exit route used was listed as "none" on the drill conducted on 7/29/15.
The facility conducted a fire drill on March 16, 2015. The exit route used was listed as "none".
The facility conducted a fire drill on April 3, 2015. The exit route used was listed as "none".
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The staff of Alpha House will be informed of the correct hours for conducting a "sleeping hours fire drill" at he staff meeting scheduled, June 4, 2015. The Executive Director will be responsible for providing this information and it will be documented in the staff meeting minutes as well as the documentation of future "Sleeping Hour Fire Drills".
The staff of Alpha House will be informed of the correct procedure for completing the "Fire Drill report", listing routes and alternative routes taken by participants. This will be conducted on June 4, 2015 in staff meeting. The Executive Director will be responsible for providing this information and it will be documented in the staff meeting minutes. The Executive Director will be responsible for ensuring that the night fire drill occur at least once every 6 months. |