INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Milestone Centers, 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 the review of personnel records, the facility failed to ensure that staff 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 within the required timeframe, in one of one record.
Employee # 1 was hired as the project/facility director on April 1, 2018. The required training was due to be completed by April 1, 2020. There was no documentation the training had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 will be scheduled with the next available virtual HIV and TB/STB trainings. Goal completion date with be June 30. Moving forward, all employees will complete the TB/STD and HIV/AIDS trainings in the required timeframes |
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 the review of the fire drill logs, the facility failed to document that fire drills were conducted at least once a month.
The fire drill logs were reviewed from March 2020 to February 2021. There were no fire drills documented for the time reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire drills had been suspended due to a misinterpretation of COVID policies. Fire drills have been restarted and will be completed monthly. If staff are not present in the building due to the provision of telehealth, the project director or delegate will ensure that fire drills are completed, regardless of the presence of people in the building. |